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HomeMy WebLinkAboutBLDG-23-005839 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 20,2023 PERMIT# BLDG-23-005839 r— JOBSITE ADDRESS 344 FOREST RD OWNERS NAME AMY OBRIEN G OWNER ADDRESS 344 FOREST RD SOUTH YARMOUTH 02664-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 111 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 1 _ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/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 © 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 Mcelroy LICENSE# 15993 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: TIMOTHY M MCELROY ADDRESS. 70 Cranberry Highway, CITY Saaamore STATE MA ZIP 02561 TEL FAX CELL EMAIL tim ancapecodmasterplumbers.com • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE Yes No \ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES 6.oa �_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK (`y CITY: l Ou t)"L 1-11MA. DATE:OL 11 /,Z 3 'PERM{f# Z 3 �'U S >� 1 JOBSITE ADDRESS: 3 L4L4 A V P S fi R A 0 ER'S,$AME: Q' ��-Q/1.1 SOS) G OWNER ADDRESS: T : A j 7 -,�S-a S FAX: TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL @ PRINT CLEARLY NEW:0 RENOVATION:K] REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ APPLIANCESI FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - - BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ DRYER 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE lr} INFRARED HEATER w LABORATORY COCK cIT MAKEUP AIR UN OVEN POOL HEATER ROOM/SPACE HEATER • .J ROOF TOP UNIT fi TEST I :Z UNIT HEATER I,V UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE % C' I have a current nubility insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑-k If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY ) 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 ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this appkcation 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''T't YLt 4.f't.i Gi�tnr Q LICENSE# , i� 9 3 SIGNATURE COMPANY NAME:_;'� .k_ C. 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