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Home My WebLink AboutBLDG23-002604 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ek,,,,,,_ s 1- CITY YARMOUTH MA DATE November 10,202', PERMIT# BLDG 23 002604 e. ‘16 JOBSITE ADDRESS 43 PLEASANT ST OWNER'S NAME KANE RICHARD G OWNER ADDRESS 43 PLEASANT ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 GENERATOR GRILLE 1 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 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 (Herbert Healis I LICENSE# 20177 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑#I Inc 0#I I COMPANY NAME: IHERBERT M HEALIS I ADDRESS. 178 STUDLEY RD, I CITY IS YARMOUTH I STATE IMA I ZIP 1026642906 I TEL I I EMAIL 1 FAX ( I CELL I I Ihhealisvahoo.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES �'., MASSACHUSETTS UNIFOR lI APPLICATION FOR A PERMIT TO PERFORM GAS FITTING ` "� WORK i , N C RYA i '',�f/lo e, li, MA DATE F # 1-' 2 4 v .1K7- PERMIT l JOBSITE ADDRESS -k.5 ,A? - 1,/1/ OWNER'S NAME 0////,o ,- G OWNER ADDRESS 3a-/---.z.,- f TEL FAX TYPE OR R T OCCUPANCY TYPE COMMERCIAL ^ EDUCATIONAL LiRESIDENTIAL [' CLEARLY NEW: cit'' RENOVATION: ❑ REPLACEMENT: ❑ PLANS, SUBMITTED: YES ❑ NO Fi APPLIANCES 71 FLOORS 6Sivi 1 2 3 1 5 F 7 8 9 11 11 12 BOILER BOOSTER _____ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR - i ' . FURNACE GENERATOR GRILLE ) • INFRARED HEATER LABORATORY COCKS —_ MAKEUP AIR UNIT OVEN ` POOL HEATER . 1 ROOM ; SPACE HEATER ROOF TOP UNIT 1 - 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, NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COIVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X DINER TYPE INDEMNITY 17 Bohm I • 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 naives this requirement. SIGNATURE OF CHECK ONE ONLY: OWNER ❑ AGENT ElOJVNER OR AGENT 'i� 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 myknowledge `� and that all plumbing work and installations performed under the permit issued for this application will be in cornplia -. T ' ' all Perti pro ►' ion of the LtJMassachusetts State Plumbing Code and Chapter 142. of the General Laws. )7 , PLUMBER-GASFITTEF, NAME LICENSE ��'°�� 1 SIB ATUR,E MP ❑ MGF ❑ JPri JGF ❑ LPG' ❑ CORPORATION ❑ f PART1 `RSHIP ❑ # LLC COMPANY NAME ADDRESSA7572,1/y CITY `> - 4,,P ' i2 ,(/,' STATE el ZIP 0,,t6 / TEL FAX CELL J 7# EMAIL f de&Jic 'c)- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY • FINAL INSPECTION NOTES Yes No THIS APPL.ICATIOi'I SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT f PLAN REVIEW NOTES