Loading...
HomeMy WebLinkAboutBLDG-23-001629 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r f CITY YARMOUTH MA DATE (September 27,202IPERMIT# BLDG-23-001629 JOBSITE ADDRESS 11 CROSBY ST OWNER'S NAME nary fincus G OWNER ADDRESS 11 CROSBY ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 60 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES NO FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE 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 1 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 Peter Fencer LICENSE# 13512 SIGNATURE MP©MGF❑JP❑ JGF❑ LPG! El CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: 'ETER J FENCER ADDRESS, 74 WINTER ST, CITY STOUGHTON STATE MA ZIP 020722844 TEL FAX CELL EMAIL peterfencer5(a-gmail.com S310N M31A3ZI Ndld #±I J Jd $ :33d ❑ ❑ 111*I3d 3H1 Sd S3AH3S NOI1HOIlddd SIHJ oN saA S310N NO1103dSNI 1VNId AlN0 3Sf1 d0103dSNI H0d 30Vd SIH1 S31ON NO1103dSNI WO HOf1021 ACHUSETTS UNIFORM APPLICATION FORpA PERMIT TO PERFORM GAS FITTING WORK t:VL MA DATE //� 2 C Y l��l 1 2o1Z PERMIT fr z 3` I z c JOBSI E DRESS 1/ r,vIos j- y S7l'e OWNER'S NAME a C ' UIL N DEPq / Y - ----11 1_► __ T_A DRESS --CA'/�G TEL 6�S y-2 .X Fn TYPE OR PRINT PE OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:g RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO,Fli APPLIANCES 1 FLOORS-4 ESM 1 2 3 4 5 6 7 BOILER g 9 10 11 12 1; 1. BOOSTER CONVERSION BURNER ___ COOK STOVE DIRECT VENT HEATER DRYER __ ___.L_ FIREPLACE FRYDLATOR FURNACE GENERATOR r GRILLE INFRARED HEATER _ �— LABORATORY COCKS MAKEUP AIR UNIT • OVEN • POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT ' TEST UNIT HEATER - --- UNVENTED ROOM HEATER - t WATER HEATER OTHER 1 INSURANCE COVERAGE I , 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 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. SIGNATURE OF OWNER,OR AGENT CHECK ONE ONLY: OWNER El AGENT 0 `'i: I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi - the best e o knowledge IJ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p e '' "`sin of the PLUMBER-GASFITTER NAME ���i /e c'e/ LICENSE /� SIGNATURE MP, IMF❑ /JJPP ❑ JGF El LPGI ❑ CORPORATION❑4 PARTNERSHIP 0# LLC COMPANY NAME /i /e/- /G nC 04 �i / ❑ �i �'z''�Y un, �ADGRESS �� iv - ,—S7S-tG .14 CITY ---r14v 94h'7 STATE �G1 ZIP 6910 22 TEL FAX CELL 6i/7 �� ,"3 qq //' //EMAIL�G9C-t�.��ci ��>� �% COS ItOUGI GAS II'(S�E i IGP�I�I{3 I S_ THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT tI PLAN REVIEW NOTES