HomeMy WebLinkAboutBLDG-22-003295 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
c CITY YARMOUTH MA DATE December 09,202'PERMIT# BLDG-22-003295
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JOBSITE ADDRESS 103 EXETER RD OWNERS NAME KEACH FREDERICK P
G OWNER ADDRESS KEACH LYDIA B 6 FOREST ST WORCESTER MA 01609-1704 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 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
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 El NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND ❑
OWNERS 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 Andrew Leighton LICENSE# 16130 SIGNATURE
MP El MGF❑JP❑ JGF❑ LPGI El CORPORATION❑# PARTNERSHIP ❑# LLC❑# ,
COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd,
CITY IW Yarmouth I STATE MA ZIP 026735706 TEL
FAX I CELL EMAIL IhalloilcompanUI gmail.com I
S31ON M3IA3H NYld
#111AN3d $ :33d
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S310N N01133dSNI IVN13 AlNO3Sl K133dSNI 2iO3 3Jb'd SIHl S31ON N01103dSNI SYO HJfl02i
jASSAC i? T d�v UNIFORM APPLICATION F:
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� - O A PERMIT TO PERFORM GAS FITTING WORK
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JOBScTEADDRESS /, '3 I XIZT& flV - OWNER'S NAME RE O HeAcZr
OWNER ADDRESS ' T E'L FAX
TYPE OR
PRINT j, OCCUPANCY TYPE COMMERCIAL EDUCAI NAL RESIDENTIAL ''
CLEARLY NEW: V RENOVATION: R_. t�L t. PLANS�.CEMEN_•
SUBMITTED: YES NO .V
APPLIANCES 1 FLOORS- j 3sM 1 1 i 2 3 4 E s 1 $ } 7 i 3 1 9 10 } 11 { 12 } 13 14
BOILER I t
I `• € f # f
BOOSTER f _i - ,� }
CONVERSION BURNER t 2
_ .
COOK STOVE f 1 - I - - - _ } T
• DIRECT VENT HEATER 1 1 f i .
DRYER F. ? }
FIREPLACE '1 — ► >_
FRYOLATOR f f # i ` 1
I FURNACE •# i - I
GENERATOR i I 1 1 . .1
GRILLE E F �
INFRARED HEATER f - E . _ f _ -
E ABORATORY COCKS i I + -
MAKEUP AIR UNIT _i i } ( : =r .
OVEN ? _; . . _ _ _ _ .,l.._..- 3 # .--
POOL HEATER F f 1 I _ ; . E t ._ • -- - - �.
ROOM I SPACE HEATER f I F .- _
i ROOF TOP UNIT II
s
. TEST .x >< i -i -
UNIT I-LEATER ,
UNVENTEB ROOM HEATER t i _ 4 1 _ -
WATER HEATER - . I . F I _ } .
OTHER I 1 l ' `.
I
r #
J ,
INSURANCE CO t
I have a curie t ilabilitv issuance policy or its substantial equivalent which meets the requirements of NGL.Ch,142 YES : NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE ••`PROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V OTHER -=INDEMNITY BOND
OWNER'S INSURANCE WARIER: I am aware that the licensee does not have the I - rance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my sure on this permit application vial - this requirement
I CHECK ONE 0 : OWNER AGENT
SIGNATURE OF OWNER OR AGENT i /
i hero , appffan are imO :-- , t. .1 •-;; 0!m kn
by�that ail of�e� and in�?r�c�f suf�itiea or�. �regard Y owledge
and that ail plumbing work and fnsfiallafry pied um:terms rent Issued for this appri-...n l be"Tit pifane, .. Vli Pam•- -e,.l., • of the
Messacuseffs State Pfunbina Code and Chapter 142 of the Genf Laws. I. , 10Imi --
;E PLUMBER GASFITTER NAME ANDREW LEIGHTON LICENSE ' 15130-M SIGNATURE
MP ' MGF JP JGF ICI CORPORATION ' # 3734C PARTNERSHIP # LLC #
COMPANY NAME HALL OIL COMPANY INC. ADDRESS 435 RT I
CITY SOUTH DENNIS STATE MA Tz tp.,0 TEL 508-398-3831
FAX 508-394-3068 CELL E t=.IL hailoilcompenyagrhaiicorn
. . • ....