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HomeMy WebLinkAboutBLDG-21-004589 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f CITY YARMOUTH MA DATE February 12,2021 PERMIT# BLDG-21-004589 1i4 `' JOBSITE ADDRESS 33 WOOD RD OWNER'S NAME KNOWLES RICHARD A TRS G OWNER ADDRESS KNOWLES JUDITH L TRS 123 N POND DR BREWSTER MA 02631-1929 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO ❑ FIXTURES FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE 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 Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Gary Thorup LICENSE# 10274 SIGNATURE MP© MGF 0 JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Gary D Thorup ADDRESS. 454 S ORLEANS RD, CITY IORLEANS I STATE MA ZIP 1026534826 I TEL FAX I I CELL I I EMAIL 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =�'1{` CITYl/ 4c ' i7/ MA DATE �� a J PERMIT# "2 - UU LI Sl y JOBSITE DRESS �� ) (= 2 ) OWNER'S NAME'J/ GOWNER ADDRESS , fl 4, TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL P7 PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: IZI7 PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES 11 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 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 O ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 • y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Perti -• • ovi on of the Massachusetts State Plumbing Code and Chapter 142 of th General Laws. PLUMBER-GASFITTER NAME 1 ,% ik:voti0 LICENSE #/e727 9 SIGNATURE MP [14/ MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAMEE"...*7--ria>/tvA iLJu'1-43 /P ADDRESS 1'� ' (3:::::C.,7714. •9 e??1, CITY L-.../` ' „c`it STATE M/1 ZIP TEL15 ' 2".111:37 7 .7A FAX CELL 7 ~ 74= T a EMAIL 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 f � 1