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HomeMy WebLinkAboutBLDG-23-005444 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i s CITY YARMOUTH MA DATE March 31,2023 PERMIT# BLDG-23-005444 -t'r' JOBSITE ADDRESS 118 CROWELL RD OWNERS NAME MITCHELL BUTLER G OWNER ADDRESS DENISE BUTLER SPELLMAN 77 CARLISLE RD 02673-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL II "le 5 � RE/�IDEr�TIAL III PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO El 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 1 FIREPLACE FRYOLATOR FURNACE 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 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 Donald Raymond LICENSE# 25836 SIGNATURE MP❑ MGF 0 JP© JGF❑ LPG' ❑ CORPORATION El# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DONALD L RAYMOND ADDRESS. PO BOX 522, CITY YARMOUTH PORT STATE MA ZIP 026750522 TEL FAX CELL EMAIL expertenergyhvacangmail.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 ' CITY: > 'al(�V� '> �"��/-7 L -sus--y , = MA. DATE: c7PR () •� PERMIT# / JOBSITE ADDRESS:t.lCj Q. j OWNER'S�NAME V�1 11_ C,6--k.k.. .-- G OWNER ADDRESS: 1;k k�- - TELit i'C <Li' k. j TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Q/ PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:4?:( PLANS SUBMITTED: YES❑ NO[2 APPLIANCESZ FLOOR-• Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 'BOILER - BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER ,y FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE VI INFRARED HEATER 411 LABORATORY COCK k MAKEUP AIR UNIT q OVEN POOL HEATER . F_ ROOM l SPACE HEATER ��" .'' F ...D \ r -1 ROOF TOP UNIT l .Z NITHE4TER i ; MAR2623, t,V UNVENTED ROOM HEATER .1. ' �, - J WATER HEATER /"' i, QM! DI(yL, L.) ,i-Fl I ENT 1� i i, - '1 INSURANCE COVERAGE � I have a current iibility insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES tE N0 ❑ If you have checked YES,please indicate the type of coverag,by checking the appropriate box below. LIABILITY INSURANCE POLICY _e--"% OTHER TYPE INDEMNITY ❑ 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. CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this appication are tru nd a to the best of Knowledge and that all plumbing work and installations performed under the permit Issued for this application v4I1 In ce iP nt provision of the Massachusetts State PlumbCode and Chapter 142 of the General Laws. ` ',:PLUMBER/GASFITTER NAME � y �� LICENSE — G RE COMPANY NAME: � ii'' `` ADDRESS: ^~ `- p` \� CITY:_ * STATE: U , ZIP:J Z 6� FAX: TEL t t` t- (4 " LL: EMAIL?Of rATil ,A 1 (�l1 , MASTER❑ JOURNEYMAN LP INSTALLER❑ CORPORATION 0# PARTNERSHIP❑# LLC❑# C h7, /L ADZNLe.SS : 7 4 VS—"r f --z J\\f PI %,-