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HomeMy WebLinkAboutBLDG-21-006633 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK „_` - CITY YARMOUTH MA DATE May 17,2021 PERMIT# BLDG-21-006633 F JOBSITE ADDRESS 528 FOREST RD OWNER'S NAME TOWN OF YARMOUTH SENIOR CTR 1 G OWNER ADDRESS 1146 ROUTE 28 SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 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 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. 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 AI Cassano LICENSE# 9015 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 8 Fruean Ave, CITY S.Yarmouth STATE MA ZIP 02664 TEL FAX CELL 5087769536 EMAIL SIDL CAPECODMECHANICAL.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 St: ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kt, ='!�z f " CITY ��ARt�1c T►� _ MA DATE 05 (t5 2021 PERMIT# JOBSITE ADDRESS 528 FOREST ►ED. S.jARt��t-1 . OWNER'S NAME of'1A n{ G SENIOR Cam. OWNER ADDRESS l 14ROLLTE 2B, S. ARfnxxjiti TEL(506)' 14-1606 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL t EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION;❑ REPLACEMENT: Z PLANS SUBMITTED: YES 0 NO El APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I 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 I SPACE HEATER ROOF TOP UNIT ' TEST UNIT HEATER UNVENTED ROOM HEATER ' WATER HEATER OTHER INSURANCE COVERAGE I have a current liability Insurance policy _:r its subct ntls!equivalent which masts the requirements of MGL.Ch.142 YES re. O 0 !IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY e 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 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ere 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 complianc it II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBER•GASFITTER NAME A I C .-ei ay. L!CENSE#90 if `�� ���� SIGNATURE MP( MGF E] JP❑ JGF 0 LPGI ❑ CORPORATION Eft .3o 16 PARTNERSHIP 0# LLC❑# COMPANY NAME- C ,c t cod fr1.4 a1. ch.0 c* I ADDRESS $ rr4, e ' L,. 4Vey CITY .5. Y..4,- 0", -4'44, STATE hi I1.._ ZIP CO .2 if C 50? TEL .1-0 a„1941— 7J o r FAx '!;'O .19 6,-7r 7 e CELL ,11"ci ' rf 7 0 ._.. EMAIL SideCo"l t.:/Yh-tcA,ghrLc I . Crr✓v, (n$C cQfPccdmerhAn%Cal.Coal