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HomeMy WebLinkAboutBLDG-21-005653 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 31,2021 PERMIT# BLDG-21-005653 t-E 1 JOBSITE ADDRESS 20 ELLIS CIR OWNER'S NAME MOSER MARCIA J(LIFE EST) G OWNER ADDRESS 20 ELLIS CIR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 1 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 0 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 Andrew Leighton LICENSE# 116130 I SIGNATURE MP© MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: IANDREW R LEIGHTON I ADDRESS. 20 Brewster Rd, CITY IW Yarmouth I STATE MA ZIP 1026735706 I TEL FAX I I CELL 1 I EMAIL Ihalloilcompany angmail.com I S310N MJIA32:1 NVId #111%13d $:33d ❑ ❑ 'Mad d 3Hl SV S3A?13S NOIlVoIlddV SIHl oNSA S31ON NO1103dSNI 1VNId AINO 3Sf1210103dSNI UOd 30Vd SIHl S31ON NO1103dSNI SVO H000N — '' MASSA tHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY td I9 l31`-t 0 t2 1 v R 1-- MA DATE Y.--,c .A PERMIT# ( � G' Z( cx s c >3 J08S(TE ADDF :SS . C.'" 1� l is r' OWNERS NAME fr1'} R C 11(4 + C)S eV., OWNER ADDR SS It T1SDFSE�PPAX _ TYPE R. OCCUPANCY 1 'PE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY I NEW: F :NOVATION: REPLACEMENT: - PLANS SUBMITTED: YES NO 1/ BOILERAPPLIANCES 1 FLOORS-' BSM J 1 I 2 1 3 11 4 I s i s 7 1 8 9 10 11 I 12 ( 13 14 . I BOOS!tN. - I CONVERSION BURNER COOK STOVE I I } I DIRECT VENT HEATER } ff I f 1 DRYER I • FIREPLACE I ; I . I I I I I FRYOLATOR FURNACE I I. i .. . I 1 I I. I L i . I ! I ' - I . l GENERATOR GRILLE J I 1 I 1I INFRARED HEATER I LABORATORY COCKS - MAKEUP AIR UNIT I I I I I ! _. OVEN j i POOL HEATER I -- { I I ROOM I SPACE HEATER j I ! I I ROOFTOP UNIT J TEST t :: I UNIT HEATER 1 UNVENTED ROOM HEATER J I i I WATER HEATER - I OTHER I I I I I INSURANCE COVERAGE I have a current liability insuranc policy or its substantial equivalent which meets the requirements of NIGL Ch.142 YES ./NO I IF YOU CHECKED YES,PLEASE IN ICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY t3SURANCE POLICY V OTHER TYPE INDEMNITY BOND OWNERS INSURANCE WAIVER: am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,an that my signature on this permit application waives this requirement. CHECK ONE 0 Y: OWNER AGENT SIGNATURE OF C VIER OR AGENT I hereby certify that all of the details s td information I have submitted or entered regarding this applcation are a and a of my Knowledge and that all plumbing work and instal trans pert rmeo under me permit issued for this application will be in plan vy� II P iti re - ion of the Messachusefis State Plumbing Code and Chapter 142 of the General Laws. / r F PLUMBER-GASFITTER NAME AA LICENSE:�,REW LEIGHTONi' 169s4-ICI SIGNATURE l NIP � MGF JP JGF LPGI CORPORATION ' i";! 3734C ADDRESS 435 RT 134 PARTNERSHIP -.1, LLC r COMPANY NAME HALL OIL CON =NY INC. CITY SOUTH DENNIS STATE MA ZIP 02660 TEL 508-398 383 I FAX 508-394-3088 CELL EMAIL halioilcompanyOgmail catn