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HomeMy WebLinkAboutBLDG-22-000627 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 ` re CITY YARMOUTH .1 MA DATE August 04,2021 PERMIT# BLDG-22-000627 JOBSITE ADDRESS 103 EXETER RD OWNER'S NAME KEACH FREDERICK P G OWNER ADDRESS KEACH LYDIA B 6 FOREST ST WORCESTER MA 01609-1704 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 FRYOLATOR FURNACE GENERATOR GRILLE 1 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 ❑ 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME [4NDREW R LEIGHTON ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP 026735706 TEL FAX CELL EMAIL halloilcompany(1gmail.com S31ON M3IA32!NVld #LI1A1213d $:33d 1IW83d 3H1 SV S3A$3S NOI1VOIlddV SIHI oN saA S31ON N01103dSNI 1VNId AINO 3Sfl H0103dSNI 210d 3OVd SIHI S310N NO1103dSNI SVO HOl021 .a' MASSACHUSETTS UNIFORM APPUCATION FO A PERMIT TO PERFORM GAS FITTING WORK 4—• * 1-=1 CITY Gv 19 n t Le e,U r-/-I MA D TE , �/ PERMIT# L 1- - (6'Z f JOBSITEADDRESS /03 4- E r-s-Al R 0OWNER'S NAME r h'EO «�"It C!4 GOWNER ADDRESS ' ' '" TEL FAX TYPE OR OCCUPANCY'TYPE COMMERCIAL PRINT +sNAL RESIDENTIAL CLEARLY NE1V: /RENOVATION: REPLACEMENT: • PLANS SUBMITTED: YES NO 17 APPLIANCES 1 FLOORS-, IMMIUM©©_EH s 7 8 9 10 11 1 12 1 13 14 BOILER NM BOOSTER � . -MINI , . CONVERSION BURNER COOK STOVE =�11 I I I • DIRECT VENT HEATER DRYER 11. 1 11f FIREPLACE —I_1111111111111111 1 I FRYOLATOR . _ .( _ . . I __...1-_.._ =II f I ®® _ FURNACE imams GENERATOR f EMI 1 GRILLE - "I__'_ INFRARED HEATER LABORATORY COCKS '�' I _ =ice_ _= MAKEUP AIR UNIT OVEN _MS 11.1I 111111 POOL HEATER ROOM I SPACE HEATER ��'� I - ROOF TOP UNIT ���� I TEST NE � .11111.11 UNIT HEATER 111111111111.M.1I =��_ UNVENTED ROOM HEATER 1 1 MOMIIIIIIIMMIN WATER HEATER OTHER 1111=1.111111111111111111=111.11 11111' 1111111.11 MEM alIMMOMMI ? I 111111 I 1 INSURANCE COVERA e- I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ./NO I IF YOU CHECKED YES,PLEASE INDICATE E THE TYPE OF COVERAGE BY CHECKING THE -PROPRIATE BOX BELOW IARILITY INSURANCE POLICY it/ OTHER TYPa INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the in- rance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on,this permit application wai this requirement. f_____-_ SIGNATURE OF OWNER OR AGENT CHECK ONE : OWNER QGE I hereby certify that all of the details and info„:ia an I have submitted or entered / and that at Plumbing work and trtst aeort5op app will be n era.. a and "-�- . ... of myon of the Performed under me permlt Issued for this appii•_ ".n be in... Allan -7r :�;:'on of the MBSSaChusefi8 State Plumbing Code and Chapter 142 of the General Lam. i I PLUMBER-GASFITTER NAME ANDREW LEIGHTON �'J UCr=NSE ' 1E130-M SIGNATURE MP • MGF JP JGF LPG CORPORATION + TM C 373e PARTNERSHIP t LLC # COMPANY NAME HALL OIL COMPANY INC. ADDRESS 435 13 CITY SOUR DENNIS STATE MA ZIP a'S60 TEL 5Q8 398 383f FAX 5Q8-394,3068 CFI I EMAIL hallcicom p�Y@gtnait.corn J