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HomeMy WebLinkAboutBLDG-23-004924 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l'kl` 'j= CITY YARMOUTH MA DATE March 08,2023 PERMIT# BLDG-23-004924 JOBSITE ADDRESS 174 WINSLOW GRAY RD OWNERS NAME FABRICO PAINTING INC G OWNER ADDRESS 35 WASHINGTON AVE WEST YARMOUTH MA 02673-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO ❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 1 OTHER 1 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 El 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 (Robert Wilson LICENSE# 24338 SIGNATURE MP❑ MGF El JP❑ JGF❑ LPGI El CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [ROBERT WILSON ADDRESS. 50 LAKE RD, CITY WEST YARMOUTH STATE MA ZIP 026733743 TEL FAX I CELL EMAIL willidod50(a.icloud.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 'tp.zz- .y E 9ASSACEHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK M6 2 ? ITY L/✓t s �J7 Imo, DATE 5 S )-L=�-3. PE MIT# 06Y a JOB TE ADDRESS t�4/ wr�tS/e:w C, fP 2 (� /� B ILDI t EPAR7 r / OWNER'S NAME f4q! Iry !/t ail-Azl 0BY - _ ____._Q1NNEtR f1DDRESS TYPE OR TEL FAX PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: EY- PLANS SUBMITTED: YES❑ NO El APPLIANCES ' FLOORS-4 BSM 1 2 3 4 5 6 BOILER o 9 10 11 12 13 14 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 f SPACE HEATER —�--I ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER ,�/ I - --____LI OTHER UV7S`7t Gc.li J- -----# r _ I INSURANCE COVERAGE 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 THE TYPE OF COVE E ICY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY El BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the i Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ElAGENT E] •• 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 c Ha ce with all Pertine Massachusetts State Plumbing Code and Chapter 142 of the General Laws. provision of the PLUMBER-GASFITTER NAM 7" LICENSE#)Yf3i SIGNATURE MP❑ MGF❑ JP C JGF/111 LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑ COMPANY NAME LSO S elvi lbi " I/r�r 7 ' P /1 �S n S ADDRESS Y� n�b� g -C ram( a CITY ()0`f"S STATEii— ZIP 0;43,te- TEL FAX CELL f77Y 353 dt>i c " co A EMAIL v✓t II� c\ � D C c•f .C,i-►'\ ------ ---- • SOUGH 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