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HomeMy WebLinkAboutBLDG-23-004799 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 01,2023 PERMIT# BLDG-23-004799 JOBSITE ADDRESS 50 GROUSE LN OWNER'S NAME MARK HAYNES G OWNER ADDRESS LISA HAYNES 4 HUMMELL LN SOUTHWICK 010770000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN l POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 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 0 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 David Casey LICENSE# 25206 SIGNATURE MP 0 MGF 0 JP© JGF 0 LPG!❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: DAVID E CASEY ADDRESS. 11 HUNTERS TRL, CITY SANDWICH STATE 1-1 ZIP 025632701 TEL FAX CELL EMAIL capecomfortsystems@,gmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE: $ PERMIT# PLAN REVIEW NOTES r- + Z11-1USEZTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK *V: ) 341Y - Z3 vc�5�797' CITT' :��Y�n �, A MC't tr MA. DATE: 3. ) " 2-,3 PERMIT# ,� 1{,( .AC DR SS: a ('PLICLE Lf OWNER'S NAME N 3Z iL t JCS a U ' G D E O1A NER: S: 5 ('"342)o, E J s1 yx}+L✓I O!,'i-4EL: 4)3. 30g ' o (tFAX: —� :61,`t,'UPANCYT('PE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL. PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑X PLANS SUBMI i l ED: YES❑ NO21 APPLIANCES• FLOOR Bsmt 1 2 3 4 5 6 7 8 8 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _ FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER W LABORATORY CC)CK MAKEUP AIR UNft c OVEN POOL HEATER ROOM I SPACE HEATER �I ROOF TOP UNIT fi TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES (la NO 0 If you have checked please indicate the type of coverage by checking the appropriate box below. / LIABILITY INSURANCE POLICY j J 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 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this applcation 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, mpllance with all Pe ' ent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. C (i ,, , DLIU- PLUMBERIGASFITTER NAME:.Z 4 D �'- CALE LICENSE#L-�LC+(� SIGNATURE COMPANY NAME: _ADDRESS: /f /'L.' /Wii CITY: tTw/C•H STATE: /7f ZIP: 6) 53 FAX: TEL: CELL: 66'635(' EMAI(�11'�D, rid< y 'kL r�_ Y#)1( C c MASTER❑ JO JRNEYMAN J LP INSTALLER❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# c/ , . ADL1tze-ss : /on