HomeMy WebLinkAboutBLDG-23-003302 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE December 13,202; PERMIT# BLDG-23-003302
JOBSITE ADDRESS 1 GREEN TEAL WAY OWNERS NAME FREEMAN MARTHA LOUISE
G OWNER ADDRESS 1 GREEN TEAL WAY YARMOLTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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 1
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❑ BOND ❑
OWNER'S INSURANCE VVAIVER: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 tt a details and information I have submitted or entered regarding this application are true and accurate to the best of my
knowledge and that all plurnbing 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 Warren Burrell LICENSE# 13628 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑
COMPANY NAME: [NARREN T BURRELL ADDRESS. 105 SANTUIT POND RD,
CITY MASHPEE STATE MA ZIP 026492430 TEL
FAX CELL EMAIL burrellplambinq(@.aol.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
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
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r• - --JOB- Al RESS i (jr C.,:_1/4„rt l ec,_l �)' OWNER'S NAME 44..—t-koi- ;7g___-
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Buie OR d TYPE COMMERCIAL By ;If�r�Er;� � N ❑ EDUCATIONAL ❑ RESIDENTIAL['
I - r: a RENOVATION: ❑ REPLACEMENT: Er PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 'l, 1"
BOILER
BOOSTER ' -- — I
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER ' II 11
DRYERI
FIREPLACE
FRYOLATOR '
FURNACE I
GENERATOR
GRILLE —J
INFRARED HEATER --i
LABORATORY COCKS !
•
MAKEUP AIR UNIT ' i
OVEN i
POOL HEATER •
ROOM i SPACE HEATER
ROOF TOP UNIT
TEST .
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
}
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES BID ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY cay 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
1,•• 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.
41 LA)' ---- — --.
PLUMBER-GASFITTER NAME ...).-‘.4-r't,.-i .i rrclN LICENSE# ( 3(,Z_YY SIGNATURE
MP 1 P MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑#i PARTNERSHIP❑# tic❑#
COMPANY NAME"13-,fr�`t ,eck (I —
ADDRESS I�:� .5-;—I( J., ►—
e 4' -�J kL L
CITY M�-J4Yet STATE)\-Ai9" ZIP C>2.C,LA°I TEL Sc':0 -5Z"1-\--k-KYC)
FAX CELL EMAIL YY-6.^ i) 1.)uvtV, ..�,s,-+' "tol .c �w
ROUGH GAS INSFECTION NOTES THis VAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes N
THIS APPLICATION SERVES AS THE PERMIT l
FEE: $ PERMIT ft
PLAN REVIEW NOTES