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HomeMy WebLinkAboutBLDG-21-002981 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rr_ / CITY YARMOUTH MA DATE `November 25,202( PERMIT# BLDG-21-002981 JOBSITE ADDRESS 105 EILEEN ST OWNER'S NAME DONOVAN ROBERT L G OWNER ADDRESS DONOVAN CINDY L 105 EILEEN ST YARMOUTH PORT MA 02675-2008 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: m 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 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:underground I.p.gasline 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 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Michael Lafortune LICENSE# 1150 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG! El CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MICHAEL Z LAFORTUNE ADDRESS. 300 OAK ST, CITY HARWICH STATE MA ZIP 026451940 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ Pre/ems— — 00V //�p�o FEE:$ PERMIT# PLAN REVIEW NOTES . a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' R (OiiH Poi r MA • DATE r l 1I / 2 PERMIT 'ram r � i • t' >O'/t5 v 4'�!i�� JOBSITE ADDRESS ( i') 1 (,, -6__ A-!' .OWNER'S NAME. . Gi ADDRESS TEL FAX _ OWNER D .... ' TYPE O EDUCATIONAL ❑ RESIDENTIAL OCCUPANCY TYPE COMMERCIAL. � PRINT � - � � !, t-� REPLACEMENT; � PLANS SUBMITTED: YES 0 NO � CLEARLYNEW: 0 RENOVATION: REPLACEMENT, APPLIANCES 1 FLOORS'''. 1 , 2 3 T f 5 6i .��! , . 1 BOILER _ ' -.. , I .-----�- BOOTER ! 1 ' - .-I CONVERSION BURNER - ' 1 + + DIRECT T HEATER " � �� �.. i j I E �! E 1 FIREPLACE:PLACE ; f , i + M- -- F RYOLATO�i I . i , 1.,,,_.�.+. I i + i `` FURNACE + r 1 ,.--�-- GENERATOR _ ' ' ' LLB �., INI=RAREI NEATER _ , ! i SUP AIR UNIT j ' .. —.--.- i POOL HEATER i I i ► _ . _ R: : r SPACE HEATER ` ! i I RAF TOP UNIT i I . - - . .. TE �,�. ..�. . I i ! �. _ r f U�E i � 1, t ...,...,.....�,-.�.. - - ,!T NEATER 4 .�.�..�..r,.....�•���..�;.�,..�:��-�-�-q' i� _ -..� ,I .�._____-��.�.�.. EN D ROOM HEATER I , 1 l r 1 WATER HEATER ,_.,. { ,_,.., �......, OTHER 5 .. '. ..-_... :... 1 . -5...... .A•.. • INSURANCE 6MVEg/44E ,a rot !. gI „a `:I , II uNNraierit whicheits the raquiretents of MGL Ch. 142 YES NO i._,..i IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF C F.RANE SY CHECKING THE APPROPRIATE SOX BELOW LIABILITY INSURANCE POLICY ; OTHER TYPE INDE N, .,; 7 BOND 0 OWNER'S INSURANCE NER:. La ; acre that the license ` Ea the insurance coverage required by Char 142 of the iiiestachusettit tlenerai Lain, and the .may signature on this perms application waives this requirement. CHECK ONE ONLY: OWNER D AGENT Q SIGNATURE OF OWNER OR AGENT _ y !icy rax �, rftra Leis eT I rrit0711 ,1 subr d ar entered regenling this application are true anti a-c'euriete ,o the b t.Of my 1 nowi L,; ers: that ail plumbing *004 and installations ;o n ed under to pent issued for this appii, ;icn will In oornpli, r; • with all Pe 'tint provision of the Machu$ State Plurnbing C .e and Chapter 142 of the Genera! Laws. 1 , , Te.; PLi, MBER-GASI+ITTER NAME . (telyiet 6.LEZZA.).,:t../t.: LICENSE # /1 6 SIGN. MRE MP ``J MGF IT JP JGF � LPG! CORPORATION 0 # PARTNERSHIP 0 # LLC E '•Y E t- Ala. . 12� �-'.- (! .r,/OI�:PAN`3 �I�.. Wizr . .. .. .. ., ._ ADDRESS. L . �'�` ' 2 i �,�. .�.. ... STATE / i ZIP l r�({///) TEL .- �' 7, 724T '�^ i�+ +.af..�.a... ..++s,.*+..c�a !•a�!A�r� roi= i ..... -b..,.. F,,A,x ?4 J ' ✓ • CELLYi2fJ7±'L . EMAIL2 te l 4