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HomeMy WebLinkAboutBLDG-21-002665 __ f 4 fit 5A r I Co�r t_ . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `, a CITY YARMOUTH MA DATE November 10,202( PERMIT# BLDG-21-002665 JOBSITE ADDRESS 15 WHIPPOORWILL LN OWNER'S NAME ELDERKIN EUGENE E G OWNER ADDRESS ELDERKIN ERIN P 15 WHIPPOORWILL LN YARMOUTH PORT MA 02675 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 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 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 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 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 Daniel Maybruck LICENSE# 12097 SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPG' 0 CORPORATION❑# PARTNERSHIP El# LLC 0# COMPANY NAME: FANIEL A MAYBRUCK ADDRESS. 9 HERRING POND RD, CITY PLYMOUTH STATE MA ZIP 023606903 TEL FAX CELL EMAIL infoRmaybruckplumbinq.com , l ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No /Zc-=-o (-FS THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tw I=r CITY Yarmouthport MA DATE 11.04.2020 PERMIT # BC6G—ab_.--Ob2(00S. JOBSITE ADDRESS 15 Whippoorwill Lane OWNER'S NAME Eugene Elderkin GOWNER ADDRESS 15 Whippoorwill Lane TEL 508-833-2959 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES -1 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 1 _ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ..,. , ROOF TOP UNIT RECEIVED--; TEST ---- ----M..�._ UNIT HEATER UNVENTED ROOM HEATER '•' `�� }'j WATER HEATER OTHER JBUILDGD?1FNT INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 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 m, knowledge and that all plumbing work and installations performed under the permit issued for this application will be i co ' ce with all P rtinent provisi,,n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Dan Maybruck LICENSE # M12097 SIGNATURE _ MP MGF v ,iP JGF LPGI CORPORATION i # 2865 PARTNERSHIP # LLC # COMPANY NAME: Dan Maybruck Plumbing & Heating Inc. ADDRESS 9 Herring Pond Rd. CITY Plymouth STATE MA ZIP 02360 TEL 508-833-2959 FAX 508-888-7811 CELL EMAIL info©maybruckplumbing.com lb. 7., 1 • • y