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HomeMy WebLinkAboutBLDG-21-005017 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � F! CITY YARMOUTH MA DATE March 05,2021 PERMIT# BLDG-21-005017 lE JOBSITE ADDRESS 32 COUNTRY CLUB DR OWNER'S NAME susan mckenna G OWNER ADDRESS 32 COUNTRY CLUB DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 r 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER r 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 Kesuqs Lopez LICENSE# 16301 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: KESUQS LOPEZ ADDRESS. 107 Meetinghouse Rd, CITY Mashpee STATE MA ZIP 026492617 TEL FAX CELL EMAIL kees@evenflowplumbing.solutions 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 Ya f n1i 1A44 MA DATE (9/5/a I PERMIT# ��-1)6 7'1 C° ,JP n )/ y}1` JOBSITE ADDRESS32 (a C./L b 'PY OWNER'S NAME SWR OW-Y/4/►')cl GOWNER ADDRESS 3 (OiM1c C TEL67L1) 230.. /L/C)FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL M PRINT CLEARLY NEW:❑ RENOVATION:M REPLACEMENT: El PLANS SUBMITTED: YES❑ NO APPLIANCES 1 FLOORS--F 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 J FIREPLACE , FRYOLATOR FURNACE I GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 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 pg NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ctil OTHER TYPE INDEMNITY El 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 m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian all Pertinent n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE 430) S NATURE MP.54 MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ,joyl riot) p 1„an), ADDRESS 1D7 / <<ec o h t CITY 1CC STATE !(Yin ZIP Cg 1 TEL✓(z ) 36 I MO FAX IV ) CELL6711) 46 6 Emit YteS06'0 d k1.P Sol L Iiuvv �q� 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