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HomeMy WebLinkAboutBLDG-22-006296 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I=T- 6 CITY 'YARMOUTH I MA DATE May 02,2022 PERMIT# BLDG-22-006296 JOBSITE ADDRESS 79 WHITE ROCK RD OWNERS NAME WINGATE KIRKLAND REAL ESTATE LLC G OWNER ADDRESS 20 LINNELL LN YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL ❑ PRINT CLEARLY NEVV: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS—4 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/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 4 5 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 plJmbing 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 William Woods _ICENSE# ,11887 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: WILLIAM T WOODS ADDRESS. PO BOX 702, CITY W BARNSTABLE STATE MA ZIP 026680702 TEL FAX ]CELL EMAIL adads10/ comcast.net 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 ' •o� CITY � /emu MA DATES 22— G Z 1(p / ', a2��a_ PERMIT . JOBSITE ADDRESS 7 -J' W �o , t'!�n GOWNER'S N.AMC{'_,thj__ OWNER ADDRESS TELJ or 34.,2. !UFAy� TYPE OR PRINTOCCUPANCY T YFE COMMERCIALEDUCA T IOfd.4l CLEARLY0 RESIDENTIAL ❑ NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO re APPLIANCES-1 FLOORS BSM 1 BOILER 2 1 5 6 9 10 11 12 1; 14 BOOSTER CONVERSION BURNER I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR -- FURNACE GENERATOR GRILLE INFRARED �--- HEATER LABORATORY COCKS MAKEUP AIR UNIT • OVEN POOL HEATER R E C-. l V E L ROOM/SPACE HEATER • — _ ______L__- ROOF TOP UNIT t °2 Ma TEST GUL UNIT HEATER UNVENTED ROOM HEATER • BS�I _DitvC DEPARTMENT �— WATER HEATER y _ � __� _ __r OTHER ---------------E INSURANCE E I have a current liabIII insurance policy or its substantial equivalent which meetsG the requirements of MGL,Ch.142 YES 24)I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW a LIABILITY INSURANCE POLICY EV 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 C (Massachusetts General Laws,and that my signature on this permit application waives this requirement. . J SIGNATURE OF OWNER OP,AGENT CHECK ONE ONLY: OWNER ❑ 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 myknowledge `� and that all plumbing work and installations performed under the permit issued for this application will be in compliance with at Pertinent provision of the Nz' Massachusetts State Plumbing Code and Chapter 14 f the General owledge 1, /2,�0 Laws. PLUMBER-GASFITTEP,NAM /, �OoQ� / ,�/ LICEhJSErl SIGNATURE MP I� fu1GF❑ JP ❑ JGF❑ LPG( CORPORATION❑# PARTNERSHIP❑/t LLC❑ COMPANY, NAME CITY K �� 6/�c,�5/ ` ADDRESS d � �� / STATE ` ZIP e) o 'r �i 4 Q Q�� TELS~Dr FA CELL< O �, 7 3OS' EMAIL G7� %�I/ S7O ^/...r ell , UV -I- CZe S- /) ROUGI1ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT it PLAN REVIEW NOTES