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HomeMy WebLinkAboutBLDG-22-00184 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK hs 1s CITY YARMOUTH MA DATE July 12,2021 PERMIT# BLDG-22-000184 JOBSITE ADDRESS 33 HIDDEN ACRES AVE OWNER'S NAME SWIDER THOMAS W G OWNER ADDRESS SWIDER CARMEL A 33 HIDDEN ACRES AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 1 DIRECT VENT HEATER DRYER - —�- - FIREPLACE r r a 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 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 0 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,:he 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 jim ST.Pierre LICENSE# 16644 SIGNATURE MP© MGF 0 JP CI JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ( ADDRESS. 25 circuit rd north, CITY west yarmouth STATE AMA ZIP 02673 TEL FAX I CELL 5086851105 EMAIL JSTPIE(a HOTMAIL.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 M S C U ETT :UNIFORMAPPLICATION FOR A PERMIT TO PERFORM R A FITTING WORK i Q `: :� CIT`( MA DATE �` PERMIT # t(-0 G-- Zz- ocr)�b� • i�.LLv�. Z •_ (,�,� �w JOBSITE ADDRESS OWNER'S NAME // e 3W # k'.�— . I� ho,� , ice , Q OWNER ADDRESS .SCLN e TEL77 Q'6 f FAX ' a I T Pg I OCCUPANCY TYPE COMMERCIAL nEDUCATIONALf �ESIUE�TIAL �I P NT CUEVLIRitNE' ' '* RENOVATION: ❑ REPLACEMENT; ►= PLANS SUBMITTED: YES NO Ce 'APHLIANC FLOORS-4 6SM 1 ? 3 4 5 6 7 o g 10 '1.1 12 13 b-u1tER 1- BOOSTER ____1 CONVERSION BURNER COOK STOVE •V DIRECT VENT HEATER DRYER } FIREPLACE I FRYOLATOR FURNACE GENERATOR GRILLE l 1 INFRARED HEATER -- f LABORATORY COCKS ? • MAKEUP AIR UNIT F � OVEN 2v POOL HEATER 1 ROOM / SPACE HEATER I ROOF TOP UNIT TEST _. .._ . . - UNIT HEATER U VENTED ROOM HEATER 1,_, WATER HEATER O OTHER tp I INSURANCE COVERAGE I have a current Iiabiiit ' insurance policy or its pubs • o � substantial equivalent which meets the requirements of MGL. Ch. 142 YES 7 NO ,__, I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY IhSURANCE POLICY 7 OTHER TYPE INDEMNITY f BOND k . I ovoiERS1 INSURANCE CE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the '''') Massachusetts etts G6incrai Laws, and that my clignature n this permit application vJaives this requirement. I ``, � CHECKONE ONLY: OWNERAGENT _ •, SIGNATURE OF OWNER OR AGENT 1 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 c pliance with all P rt rent vision of the Li -( Massachusetts State Plumbing Code and Chapter .142 of the General Laws, I PLUMBER-GASFITTEP. I�IAME v fi- LICENSE # i 6 6 .4, S GNATURE MP g IMF n JP JGF n LPGI U , CORPORATION ❑ # PARTNERSHIP E # LLC n #: COMPANY NAME _ 3•1-- % \ I e ADDRESS {�� ,E�� A es l � t (C.Cl.1tT #.--R NO CITY Wej 1 1 A F, 1)71 rJ , STATE ZIP (..), 6 --) 3 TEL T O° , d ' I FAX CELL{``,SOP-6 S c�/ /0 EMAIL J i ) 1 e / )oii,4.l / 1 i Cup d 1, 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