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HomeMy WebLinkAboutBLDG-23-005374 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 30,2023 PERMIT# BLDG-23-005374 JOBSITE ADDRESS 35 KNOLLWOOD DR OWNER'S NAME DANIEL CHISOLM G OWNER ADDRESS TINA CHISOLM 35 KNOLLWOOD DR YARMOUTH PORT 02675-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:El PLANS SUBMITTED: YES ❑ NO 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 1 FRYOLATOR 1 FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS , MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 El 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 Daniel Chisholm LICENSE# 11659 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DANIEL J CHISHOLM ADDRESS. 35 Knollwood Drive, CITY Yarmouth Port STATE MA ZIP 02675-0000 TEL FAX CELL EMAIL dachisholm1990(a,pmail.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 .. I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING� L_ a I+tG lNl?RFSCITY CtT/y1?' �";�^ E r 4- MA D TE 3 3 C� - d, 171. P z3-ODS3` JOBSITE ADDRESS 3 5 kMv` d e d Y OWNERS NAME ' /E G OWNER ADDRESS TEL 78/_ q TYPE OR �+� �' �� l'/ FAX PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL NEW:❑ RENOVATION: / REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ APPLIANCES-1 FLOORS BSk1 1 2 BOILER 4 56 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER - DRYER FIREPLACE FRYOLATOR Mil III I FURNACE GENERATOR _ , GRILLE INFRARED HEATER LABORATORY COCKS R E.e i t MAKEUP AIR UNIT { OVEN V - POOL HEATER 4ARa � L • ROOM I SPACE HEATER ROOF TOP UNIT — _ , TEST B , . __ s, __� UNIT HEATER • UNVENTED ROOM HEATER WATER HEATER OTHER 11111111111 MIN IIIII INSUANCE GE I have a current lialili insurance policy or its substantial equivalentwhichvmeets the requirements of MM..Ch.142 YES ❑ NO UV 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 W El I RIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massach efts General Laws,a d that sig attire on this permit application waives this requirement. SI ATURE OF OWP�EP.OR AGENT ONE ONLY: OWNER I AGENT ID 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 myknowledge `- and that all plumbing work and installations performed under the permit Issued for this application will be in lance wl II Pertine�` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ge 1provisi ofPLUMBER-GASFITTER NAMELICENSE# 1/6Jr, !SIGTUR !1E MP V4GF❑ JP ❑ JGF LPGI ❑ rORPORATION❑#X PARTNER"'/ SHIP❑# LLC❑# COMPANY NAME / Ct/1 •/ ADDRESS 35 r rd CITY lei✓ it- C) �J� STATE/dr l�. ZIP_O. 71___ ! TEL FAX CELL7t1 - L --�y`y / / ��._ /.� � EMAIL I '! � �/1 / / * se � . , , n � . � Cl ' W 'b G, I.--i G • 1 CI I L) I [ I - I I l I I I 2❑ a I w - I U) v.1 I14, 2 w CI o 7 U ill w Fes- n tw C1.) 124 — .. . -t p^y W LLI <C o 1 G7 C�3 I -_-_-1 < b4 in W = Ili II E— IL I I \ \ V) \ I 7 I 1 U \ in \ I 4 II 1 Q 1 \ \ \ \ \ \ \ \ t I 1