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HomeMy WebLinkAboutBLDG-21-001747 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY EARMOUTH MA DATE October 05,2020 PERMIT# BLDG-21-001747 Z1%7'5 `y JOBSITE ADDRESS 81 WIANNO RD -I OWNER'S NAME LEAVERSUCH ROBERT D G OWNER ADDRESS LEAVERSUCH GAYLE L 81 WIANNO RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ 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 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:fire pit 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 Plumb ng Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Ronald Conte LICENSE# 15696 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [RONALD M CONTE ADDRESS. 283 Cranview Rd. CITY (Brewster STATE MA ZIP 026312241 TEL FAX I ]CELL I I EMAIL 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 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � .4 err '~ y .... vVl 1�c r M d _�1�=� CITY _ Uk� MA DATE C Z � 2 � PERMIT # :�� � ���"6 JOBSITE ADDRESS 1 kI I A N N O 147,, I. OWNER'S NAME Q o 6 L ( Verse C tel GOWNER ADDRESS ( ANN -o • TEL 5 °8 - `i`i - 7351FAx TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL d PRINT CLEARLY NEW: RI' RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES Z 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 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER ROOM I SPACE HEATER I a - \ rir ROOF TOP UNIT TEST UNIT HEATER • - - UNVENTED ROOM HEATER WATER HEATER .,.,._--._ OTHER 1 ' c\e. - Crc >< INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 41 NO El I iF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATJRE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or altered 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 LICENSE # I S 6 lb SIGNATURE MP 41 MGF ❑ JP F.- JGF ❑ LPG' ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME R. Ivl . C O N `e cite.c\`i Iv CA I ADDRESS c5 3 C c-avg V l e w R k . CITY rJ r-t vi S -t € K STATE M 4 ZIP U Z 6 31 TEL FAX CELL S °8 - .?- 3 - 5 7 Pi EMAIL IQ- C 0 N `ie McClGni cc. l@yA. ct ) I - Cow