Loading...
HomeMy WebLinkAboutBLDG-23-005771 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c'S'IFIN'`' CITY YARMOUTH MA DATE April 18,2023 PERMIT# BLDG-23-005771 JOBSITE ADDRESS 22 GRANDVIEW DR OWNER'S NAME AMATO SALVATORE G OWNER ADDRESS 22 GRANDVIEW DR SOUTH YARMOUTH MA 02664 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 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN • POOL HEATER ROOM I 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 El 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 Chad Poske LICENSE# 15488 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC El# COMPANY NAME: rCHAD E POSKE ADDRESS. 565 Shrewsbury St, CITY Holden STATE MA ZIP 015202194 TEL FAX CELL EMAIL chad(aposkecorp.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 r ,&-Y CITY 4��`^cv{" ` MA DATE y PERMITfr _ JOBSITE ADDRESS a a `^) 'r OWNERS NAME 'eq.) IVY T"� 'S OWNER ADDRESS c—''`'e TEL<5O7S<C1 , 's7 FAX • TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ❑ ❑ RESIDENTIAL' CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT. PLANS SUBMITTED: YES❑ N9 APPLIANCES FLOORS—I BSlul 1 2 3 4 5 6 7 8 9 10 11 12 13 1 BOILER ---- BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR l GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER • ROOM!SPACE HEATER ' ROOF TOP UNIT TEST ....._.- UNIT HEATER INVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES,'NO 0 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 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and c rap to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application wit be in complian ' aL Pertinent provision of the '`' Massachusetts State PlumbingCode and Chapter 142 of thel/t t P General Laws. 5 PLUMBER-GASFITTER NAME LICENSE ki7 SIGNATURE MP,( MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION/ 3 a� PARTNERSHIP❑# LLC❑# COMPANY NAME PoS�e- Cs C3c1 ADDRESS CITY k"--)c, ce s STATE 0 A ZIP C)1 C O TEL I C6% gG )`1 FAX CELL �'�— ' 144\ EMAIL C-SA C S `� -Co v.} . OUGH GAS INSFEC I I�t V3 DES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: $ PERMIT# PLAN REVIEW NOTES