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HomeMy WebLinkAboutBLDG-23-005198 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '(j CITY YARMOUTH MA DATE March 21,2023 PERMIT# BLDG-23-005198 J JOBSITE ADDRESS 22 HOLLY LN OWNERS NAME EGAN JAMES M G OWNER ADDRESS IEGAN KRISTA M 81 GROVE ST HOPKINTON MA 01748 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:© 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 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 1 OTHER DESCRIPTION:piping for meter 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 at 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 James Bertino LICENSE# F2033 SIGNATURE MP©MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: JAMES P BERTINO ADDRESS. 60 TELLER DR, CITY ASHLAND STATE MA ZIP 017211061 1 TEL FAX CELL EMAIL iames.bertino(a.amail.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 5o,a0 tam— At.HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • _— t t_ CITY: Q YY\ MA. DATE: <- J Z PERMIT# C- Z S'5-t`ti' * ' . 21 ibiaTE DDRESS: Z r\1 .L 1 An e OWNER'S NAME: ,\\ 34r\ 3UILDTf ; DEP-AE �DPESS: 1/� kt\\ti \( y.J TEL: _ FAX: 3y - 'OFt - PRINT 99CiAliPICY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL'( 1 C CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:gi' PLANS SUBMITTED://``� YES❑ NO❑ APPLIANCEST FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 t BOILER BOOSTER i CONVERSION 3URNER COOK STOVE r/` DIRECT VENT HEATER <1 DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR ' GRILLE V) INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER \I ROOF TOP UNIT � TEST _ UNIT HEATER i,L1 UNVENTED ROOM HEATER r WATER HEATER f INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES fNO 0 If you have checked YES,please indicate the type of coverage b} checking the appropriate box below. LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANC E WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Ma setts-General , d that my signature on this permit application waives this requirement. -ZJ _.--- -- - CHECK ONE ONLY: OWNER 0 AGENT ATURE OF OW OR AGENT // __ 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 I t all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142(Atha General Laws. --'' PLUMBER/GASFITTER NAME:_,(_'_____ ICENSE# 12 03 SIGNA COMPANY NAME; G.t1'14 [_X'Y}�,1 p P 11,b3 r() \ K 1 I t D2 CITY: "I\911\.(I i'1, STATE:MA ZIP: O l 1 2 t FAX: TEL: CELL:5 s.X e1 0 754 EMAIL: )CA?V\QI I'+i c ( of rn c t t \ (O we MASTER JOURNEYMAN❑ LP INSTALLER El CORPORATION El# PARTNERSHIP❑# J Ll C❑ c pie/c- ADIA2c--.ss : _ 1 Q m S r' \ \ (Onv, ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE: $ PERM'S ELAN REVIEW NOTES 1