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HomeMy WebLinkAboutBLDG-23-006106 . :- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '"4'4 CITY YARMOUTH MA DATE May 05,2023 PERMIT# BLDG-23-006106 JOBSITE ADDRESS 21 FRANKLIN ST OWNERS NAME DAVID ROGER RICHER G OWNER ADDRESS LACROIX DONNA M TR 119 HARWICH CT ROCK RIVER 44116-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT 0 PLANS SUBMITTED:YES❑ NO 111 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 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 Q NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY 0 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 matthew coleman LICENSE# 34368 SIGNATURE MP❑MGF❑JP© JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME MATT COLEMAN PLUMBING AND HEATIN ADDRESS. 5 college st, CITY west varmouth STATE MA ZIP 026733792 TEL FAX I CELL 9788854343 EMAIL 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 _ _ �U .O • I� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I' �'^ CITY ojklia_ � MA DATE MIT , r , -6'16/e6 JOBSITE ADDRESS VL OWNER'S NAME d G OWNER ADDRESS "Z( FrakIk`hi, s-i- TEL '9x-1 w FAX TYPE OR PRINK. OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL lif( NEW:❑ RENOVATION: ] REPLACEMENT:0 ,�/ PLANS SUBMITTED: YES L�J NO❑ APPLIANCES 1 FLOORS-4 6ShA 1 2 3 4 57 o BOILER 6 9 10 11 12 13 1R BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE GENERATOR GRILLE INFRARED HEATER - LABORATORY COCKS , MAKEUP AIR UNIT OVEN I POOL HEATER �� • ROOM/SPACE HEATER C E 1 V I D , ROOF TOP UNIT TEST . UNIT HEATER NI �+�Y INVENTED ROOM HEATER WATER HEATER � OTHER I _ i _ INSUR NCE E I have a current Iiabili insurance policy or its substantial equivalent which hicDhvmeetsG therequirements of MGL.Ch.142 YES � Eli/NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the i Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER.OR AGENT CHECK ONE ONLY: OWNER Ell AGENT El `4-. 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 NA E iwctottof (dewlap LICENSE1#3436 SIG ATURE MP ❑ MGF❑ JP 41 I JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME RaiIff C1�1210 _PS 6 _ ADDRESS CO/I e $� CITY 1Jt Jcif WO An STATE MZIP ,gyp-��73 pxe.pY- Saco TEL (L6 (14,� q3q5 FAX CELL EMAIL sia-#( to ciP7'Msada )R�TJGFI GAS IINSPEt'TIOt4 NI ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes NQ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT# PLAN REVIEW NOTES • • • • • •