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HomeMy WebLinkAboutBLDG-22-003239 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK R CITY YARMOUTH MA DATE December 07,202' PERMIT# BLDG 22 003236 II JOBSITE ADDRESS 28 CAPT BACON RD OWNER'S NAME William Brown G OWNER ADDRESS 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 1 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 i 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 Robert Brodie LICENSE# 30565 SIGNATURE MP❑ MGF ❑ JP❑ JGF 0 LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ROBERT D BRODIE ADDRESS. 184 VILLAGE LN, CITY WELLFLEET ,STATE MA ZIP 026678119 TEL FAX CELL EMAIL northcoastph(@_protonmail.com 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 fl .#`, CITY...5 -6\ MA DATE /Z -79Z 1 PERMIT# 27- 323 , l Ns JOBSITE A DRESS `'^ OWNER'S NAME t/�2-12 W OWNER ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL '� W tIT}i� ❑ RESIDENTIAL CLEA , NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES t FLOORS-4 BSIv1 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 • L—_ 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 kt NO ❑ 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 all plumbing work and installations performed under the permit issued for this application will be i with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE tt65-- SIGNATURE MP ❑ MGF❑ JP JGF U LPGILP _)[� CORPORATION❑ E PARTI r „' P❑# LLC❑# COMPANY NAMEC1 �( l l e S ��x -�yy G ADDRES, . CITY )1-1 Q,/�it�i(iti, STATE /�� ZIP C0 247'1 / TEL .2-620-2,2%3 FAX CELL EMAIL nor Cc grS7pii Q �,t4,i -Caws ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Ye5 No THIS APPLICATION SERVES AS THE PERMIT fl FEE: $ PERMIT it PLAN REVIEW NOTES