HomeMy WebLinkAboutBLDG-21-001777 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE October 06,2020 PERMIT# BLDG-21-001777
JOBSITE ADDRESS 111 CROWELL RD OWNERS NAME LADIN EDWARD L TRS
G OWNER ADDRESS LADIN KATHRYN C 2 LEAFY LN LARCHMONT NY 10538 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID
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CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO EJ
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
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER 1
ROOM!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 ❑I NO 0
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 at 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 an 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 IWELLINGTON FARIAS LICENSE# MA SIGNATURE
MP Q MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑#L LLC❑#
COMPANY NAME: (Wellington Plumbing&Heating,Inc ADDRESS. 125 Shepard Court,
CITY WINCHESTER MA STATE MA ZIP 01890 TEL
FAX CELL 7815897578 EMAIL I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
111G ak 10/1/a-0 ZD c1:5 THIS APPLICATION SERVES AS THE PERMIT j
FEE: $ PERMIT#
PLAN REVIEW NOTES