HomeMy WebLinkAboutBLDG-21-000617 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE August 11,2020 PERMIT# BLDG-21-000617
JOBSITE ADDRESS 66 COOLIDGE RD OWNER'S NAME CONNORS JOSEPH D
G OWNER ADDRESS CONNORS TRACI E PO BOX 303 WEST YARMOUTH MA 02673-0303 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
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
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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY 0 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 'Ralph Giangregorio I LICENSE# 9339 SIGNATURE
MP 0 MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME IRALPH J GIANGREGORIO ADDRESS. 1188 Route 28,
CITY 'Dennis Pod I STATE MA ZIP 02639 TEL
FAX I 10ELL EMAIL Ioffcean.3gsplumbing.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
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GL+S[IP.ANCE COVERAGE L� 0
I have a current liabilfr Ir trraz,cepto1 c Dr1[ stbsWi acul>?elati trite roes ',VE s ofUG-CM4Z '_ NC
IF you ilat checicsdyLI,p122.ceirldiCEM tile!FM of coirerauebyctr£daE]EJteepPTopyletaboar_b lord. R L ! V E D
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OWNER'S INSURANCE irIMlEF;I air:away that die licensee bow n heve 1I7g Trtsaranoe crrtrerary rag r OWE0112 Ng* -
Massahuset=a Gen -al La ..end that m y signsmre on 1.h is pa niZ&pplicsllar: :-att this rw ent. w _ __.._1
BUILDING DEPARTMENT
CHECICOI'IE II e11it n I Ar-ir 0
SIGNFiTURM OF OWNER OR ACENI
hereby cede that all of Ilia details 80 infunnelan I have subrtiiic-d for 2niarsti}regarding this applitailen are aue and eocurate to Ills best of my
Knowledge grid Met all playT,*4mi;g.sid Ifsiaileifone perfrrrnEd under Inaparrurrlssusd forage applies' nvill he in crrtplfantg with all Pertinent
pruvl ion of the Musauhusem sip Fltmbiitt�Code and Chapter? ?of the General LBWS.
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