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Home My WebLink AboutBLDG-23-005983 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r}I' CITY YARMOUTH MA DATE April 28,2023 PERMIT# BLDG-23-005983- JOBSITE ADDRESS 19 WILDFLOWER VILLAGE OWNER'S NAME RANDALL GLORIA H G OWNER ADDRESS 19 WILDFLOWER YARMOUTH PORT MA 02675-1474 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ 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 1 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 at 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 at 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 Alan Bishop LICENSE# 31513 SIGNATURE MP❑MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ALAN W BISHOP ADDRESS. 23 DANVERS WAY, CITY IHYANNIS ISTATE MA ZIP 026012500 TEL FAX I I CELL EMAIL lalan(a),awbishop.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 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7(17 t'= CITY: V t,+ r MA. DATE: 4 - 10 .,2 t►:I 3 PERMIT# ' C JOBSITE ADDRESS: ► ),f OWNER'S NAME: ( e S f P n LA. G OWNER ADDRESS: i `1 ' ; I �` ( e_! TEL: "7 7'1- S - `/7 y AX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL,{ PRINT CLEARLY NEW; ❑ RENOVATION; ` REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES-1 FLOOR-0 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 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE VI INFRARED HEATER ` LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER N ROOF TOP UNIT t TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1-0111+1- ( 2) 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 have checked YES, please Indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY fiz 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted (or entered) regarding this appkation 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. /3------ PLUMBER/GASFITTER NAME: 4-i t1 n S h 4 f LICENSE# 1 S/3 SIGNATURE COMPANY NAME: ADDRESS: )- 3 De CITY: 1 STATE: f1 ZIP: O 21 C C FAX: TEL: `7 7 `f S SC" 91 71 CELL: '7 7` ' 4' '? 7.7 7 EMAIL: /�J c�+�, �' G ' b i S It G' r . MASTER[] JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION ❑# PARTNERSHIP El# LLC ❑ #