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HomeMy WebLinkAboutBLDG-21-001770 S,/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK krt . I� CITY YARMOUTH MA DATE October 05,2020 PERMIT# BLDG-21-001770 ` V JOBSITE ADDRESS 6 PINE GROVE VILLAGE OWNER'S NAME KACZYNSKI STANLEY J TR G OWNER ADDRESS PINE GROVE RLTY TRUST 6 PINE GROVE VILLAGE YARMOUTH PORT MA 02675 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 BOOSTER CONVERSION BURNER , COOK STOVE DIRECT VENT HEATER , DRYER , FIREPLACE , FRYOLATOR , FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER , ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 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 0 BOND 0 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 Thomas Coughlan LICENSE# 8529 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: THOMAS J COUGHLAN ADDRESS. 48 HERITAGE DR, CITY WALPOLE STATE MA ZIP 020812240 TEL FAX CELL EMAIL IN ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 El FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS"F11TTING WORK j P our t CITY ---TA J�,1^l)ZG` /, ---1 �+„--� I GigueMA DATE PERMIT# JOBSITE ADDRESS ‘ Pike-(. al Vt7 i ;OWNER'S NAME S't v -541 S _1 GOWNER ADDRESS — /r -M,Y TEL ---- Fp --1 TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 'D RESIDENTIAL Vik.Wa•i�.r�.-` Lf CLEARLY 0 NEW: RENOVATION: REPLACEMENT: " PLANS SUBMITTED: YES t NO APPLIANCES I FLOORS-. Km ' 1 2 i 3 4 5 6 I 7 8 9 10 11 ( 12 13 14 BOILER i j BOOSTER CONVERSION BURNER { • - COOK STOVE i '. ! DIRECT VENT HEATER I ` DRYER i - FIREPLACE ! --" FRYOLATOR FURNACE GENERATOR 1 -' � — " GRILLE i , v INFRARED HEATER ER LABORATORY COCKS -. t.., 111111111111111 MAKEUP AIR UNIT i M M M : OVEN fi n E. POOL HEATER MIN. NE off IIIIO Nip MI ,lin all ROOM/SPACE HEATER : an mg iiMmiptil mu all ROOF TOP UNIT ; TEST NM as imine — -——aninimenol ____ UNIT HEATER M . . . Ma =It , UNVENTED ROOM HEATER —~ aim lilt WATER HEATER_--- ------- NMI OTHER --— _. I f"..... i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YEJNO 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 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 of my knowledge and that at plumbing work and installations performed under the permit issued for this application will be in co piia�with all Per�ipent proviss of--the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �p ��jj �Y�/ PLUMBER-GASFITTER NAME 7cm1�S 6AGp) 1 LICENSE# ,t,1 SIGNATtifi E MP JMGF JP F --' LPG!J CORPORATION;,Q# PARTNERSHIP;,, #' LLC J#j _ i 4.COMPANY NAME:. 4 " 't Ai f-coo tJ44ADDRESS i CITY l�l��{ t STATE al !ZIP' oak")..2_ TEL 5'pt')_--13 Pi'_ i I FAX CELL 51 ^- _ . - C I MA --nrij Q\CA1/4\ t . . 3 - .. • . _ r:i-. r..-.- ._A. ••.. ..v._ ,�?.' ., <r.+�p.. 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