HomeMy WebLinkAboutBLDG-21-003829 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
s BLDG 21 003829
i; CITY EARMOUTH MA DATE January 11,2021 PERMIT#
JOBSITE ADDRESS 99 EILEEN ST OWNER'S NAME HARRINGTON DOROTHY EST OF
G OWNER ADDRESS C/O TAPPEN JEANNE 15 DUKAS BROOK RD PLYMPTON MA 02367 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT.❑ 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 1
DIRECT VENT HEATER
DRYER 1
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
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 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 Timothy Harder LICENSE# 15311 SIGNATURE
MP Q MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: TIMOTHY P HARDER ADDRESS. 32 Siasconset Dr,
CITY Sagamore Beach STATE MA ZIP 025622724 TEL
FAX 1 CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
4 Yes No
I pp`N oh- dab-. G I_1 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE:$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
l'= CITY: -0 c.,c v‘AD‘ANATIo '� MA. DATE � i/ C-) PERMIT;
JOBSITE ADDRESS: G\ — + , �'e r �, OWNER'S NAME: 11•t e e Se
GOWNER ADDRESS: <:.�� K TEL: k
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES? FLOOR-. Bsmt 1 2 - 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE f
DIRECT VENT HEATER
DRYER I
FIREPLACE
FRYOLATOR
FURNACE _
GENERATOR
GRILLE
IA INFRARED HEATER
i LABORATORY COCK
MAKEUP AIR UNIT
OVEN
'
POOL HEATER
ROOM I SPACE HEATER •
-.I ROOF TOP UNIT
TEST
UNIT HEATER
r. E
yj UNVENTED ROOM HEATER +E D
WATER HEATER i
IV
MELT J !`
INSURANCE COVERAGE ay NC:arpt, EN
I have a current Inability insurance policy or its substantial equivalent which meets the requirements of M . ❑
If you have checked YES,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY VI OTHER TYPE 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.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
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 corn all Pt
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTER NAME: < LICENSE# Vic,.3\ 1 NA RE
COMPANY NAME: \VaCa"-c �t� ADDRESS: .�-�. `� ;45c �.-,��k
CITY: c-rvs ; _ STATE: f'A4 ZIP: L��SCL FAX
TEL: I -TO f CIA CELL: EMAIL:
MASTER t JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
C h7/3-/L ApLVZE`S5 : }'1Gr000 �L.�, ,� ^c� 4 API ..Ci ��1
...;54OW' :.,f. ~r, ' , S :r'':ts;X 1 .4 s.`ta . , s "f, .. 'E .+:, C.,''' „- .:) (1`"'-,,'vY,:, 'd- �rt , i
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