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Home My WebLink AboutBLDG-21-002913 ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I E CITY YARMOUTH MA DATE November 20,202(PERMIT# BLDG-21-002913 JOBSITE ADDRESS 2 PARSONAGE POINT OWNERS NAME EDWARDS PATRICIA Cj OWNER ADDRESS EDWARDS GEORGE 2 PARSONAGE POINT YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT.0 PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER _COOKSTOVE IRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM ISPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Cale and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME William Woods LICENSE# 11887 SIGNATURE MP 0 MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: WILLIAM T WOODS I ADDRESS. PO BOX 702, CITY IW BARNSTABLE I STATE MA ZIP 026680702 TEL FAX I ICELL EMAIL I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES iz>,.. MASSACHUSETTS UNIFORM APPLICATION FOR A. PERMIT TO PERFORM GAS FITTING WORK :�: A7,rCITY Volbeik 0te o d MA DATE l, 7 PER VII W gi;,...74A ' G JOBSITE ADDRESS ,CJ' �/ r�i/!�''} a1 OWNER'S NAME4t// u�� OWNER ADDRESS T EL e. TEL ~-- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL '" RINT CLEARLY NEW: ❑ RENOVATION: Li REPLACEMENT: PLANS SUBMITTED: YES ❑ NO j APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 '11 12 13 14 l BOILER _l__ -7 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER n-� DRYER Ell FIREPLACE Ell= FRYOLATOR minormell FURNACE 111 III GENERATOR. 11111111 GRILLE ' INFRARED HEATERLABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER 1 ROOM / SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ri' ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the iI Massachusetts General Laws, and that my signature on this permit application valves this requirement. CHECK ONE ONLY: OWNER ] AGENT ❑ •-, SIGNATURE OF OWNER OR AGENT 1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge 'S- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1.42 of the general Laws. Lo " Afl� 7 NAME/ (/ PLUMBER-GASFITTER N ( WUd S LICENSE it//y?.? SIGNATURE . MP ! 6GF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATIONf PARTNERSHIP ❑ # LLC ❑ COMPANY NAME .4 _ 9i t 5PA-6-9/Z ADDRESS g k 7G-_,)_ CITY 4)- L5i1YjJ STATE '- ZIP 0✓2- TEL 36 -3 6 2y31 FAX 26 10- (� CELL 86) 3,37? EMAIL /1 U17 f ' //2( r Co / L,2 /t 9 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES