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HomeMy WebLinkAboutBLDG-23-003156 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK [ BLDG-23-003156 i�--M.' 1-_----- CITY YARMOUTH MA DATE December 07,202, PERMIT# JOBSITE ADDRESS 7 CURVE HILL RD OWNER'S NAME HAGUE MICHELLE M TRS G OWNER ADDRESS HAGUE THOMAS F III TRS P 0 BOX 1394 ORLEANS MA 02653 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 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 1 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 OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 Mark Watson LICENSE# 3842 SIGNATURE MP❑ MGF © JP 0 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: MARK D WATSON ADDRESS. 81 CAPTAIN PERRY RD, CITY BREWSTER STATE MA ZIP 026312559 TEL FAX CELL EMAIL pieman83(cDcomcast.net . 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 PERMET TO PERFORM GAS FITTING WORK p; k CITY Yu R 6 V 1 MA DATE 1 2" - C ^ z-2' PERMIT# L I' 3 I SC. �;00=J jj J f JOBSITE ADDRESS '7 C OR 0( 1--A( L l �c) OWNERS NAME [ON .{-4 ---o FL GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRFNF ❑ ❑ RESIDENTIAL Er CLEARLY NEW:Er-RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-I BSIA 1 2 3 1 5 6 7 8 9 10 11 12 13 I BOILER BOOSTER i CONVERSION BURNER COOK STOVE c R E--V E D DIRECT VENT HEATER _ _ �_, DRYER hr �—; FIREPLACE �' WtC FRYOLATOR -.. ' FURNACE _�p� y 3 MEN UD GENERATOR t.�lIDI GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN —__I POOL HEATER • ROOM 1 SPACE HEATER ROOF TOP UNIT r TEST _ . .._..... -- UNIT HEATER II UNVENTED ROOM HEATER WATER HEATER OTHER I 1 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES h!0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er 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 1 \:'I:, I hereby certify that all of the details and information I have submitted or entered regarding this application are tru ccurat o t .t owledge and that all plumbing work and installations performed under the permit issued for this application will be in with e p v io Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4.,1 PLUMBER-GASFITTER NAME Di)f,VY-., MIS A' 00 LICENSE#SSfy SIGNATURE MP ❑ MGF n JP ❑ JGF❑ LPGI ❑ I'ORPORATION❑# PARTNERSHIP[]# LLC❑# COMPANY NAME 1\41\Z\S -,-p 0� (eR\....» c� ADDRESS <8 I cit>v1 Pe{ C y R 0 CITY ,4 UuSke C- STATE lv' A ZIP 026 1 TEL 72 Y' 2) 6-/Vsli FAX CELL EMAIL e ditto 9;1 10 I Y l CC{Si , N' 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES S Yes No THIS APPLICATION SERVES AS THE PERMIT [ I I i FEE: $ PERMIT # PLAN REVIEW NOTES