HomeMy WebLinkAboutBLDG-22-003417 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`k,,,,-. h CITY [YARMOUTH MA DATE December 15,202` PERMIT# BLDG 22-003417
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JOBSITE ADDRESS 57 WHARF LN OWNER'S NAME WILKINS ROBERT
G OWNER ADDRESS COURCIER SUZANNE 57 WHARF LANE YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: [1 RENOVATION:0 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
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 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 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 Massachk setts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LESTER WADE LICENSE# 4569 SIGNATURE
MP 0 MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: [LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD,
CITY COTUIT STATE MA ZIP 026352702 TEL
FAX 1 CELL EMAIL
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- 1'11 j:SS,: CRUSE T TS UNIFORM APPLICATION FOR A PERtdI1T TO PERFORM GAS FITTING WORK
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ti ' CITY ] (,t.lrm.U v 4- 1 Fo,- t MA DATE /3- --G, - - ( ! PERMIT Li-- '34 I")
JOBSi T E ADDRESS 1 / w S it ay-- - L- WItc1 i O ER'S NAME p.0 be,-4- tA), I K v' h 5
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OWNER ADDRESS Stet a-to 0 11 e,- TEL SO s--3 42.2- 5-1i,?+ U FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ! RESIDENTIAL
CL"" `'LY NEW:FE RENOVATION: i�_J REPLACEMENTPLANS E SUBMITTED: YES ❑ NO
APPLIANCES 1 FLOORS- asM i j�2 3 4 5 1 61 7 81 9 10 11 ( 12 13 14
BOILER ,-----., --,i h •-- .„._ _ �,. .
1
BOOSTER _..�L. ' �+ _I _____i {
_ # _ ..y" 1 t� 7
CONVERSION BURNER ---- ,_[.T.- -_•_1_ ,, __...-} ::��t.` :.._�:_;
COOK STOVE -'t�._ t :` . ' __..� - - _j� -_--�,___ ., _-.__1,_ ._ .a i
DIRECT VENT HEATER � r 4 i °� - .-.trL: c
�{� - ^ 5 _-1_ __- r h --DRYER (l ( �� ...._. � � _ �.
FIREPLACE i i —� s - 1:1-"n—sFRYOLATOR - , --�==�r-----; :�- �_-_-1 - - - _._ ,,--,::::::::::-.1.-.:�-
t AEI
FURNACE , j "'►_`_r---- r-------- :1---r. i._ ='1,_._- _ ._ _
GRILLE L - ._._:i ii `1�-,; Ii - _.1--- 1 �' t; t; :+ :i
INFRARED HEATER If
------a — l l; i 1 In-lr�'_ + �T'_ �� ,
—i 1 :I�
LABORATORY COCKS ' ~' '. fir-T. , --1;
MAKEUP AIR UNIT IETT ii ii
POOL HEATER '' . _�_ . t .,, '•`r' .-7, ._. L.
I_ _1� 7
r "fir' ',_" �r - ..�...1 r +1' ,r--=--- t!- -. 1
ROOM l SPACE HEATER I 1 I 1I
ROOF TOP UNIT II •I _ Ili !I ij _ —11 ___11..._11 ' ~_. ... :: .7
TEST il. - ..�,. , .. 1 _. ,L,_.: ..,�.i-. �-
` - i �1 itL...._..2.,......_._�....:_,..._ ,.. 1
UNIT HEATER ( j ' ' in1. y
UNVEN T ED ROOM HEATER _ •� ' f�
WATER HEATER I— ,t `i' T. I >2 11 , _; >I
.:.n.t..�.a.....a+�-:
OTHER 4. .
ti ri 1 •.! 1—'-'i .:,1 11--_-.11 , _,_ _. ,i___ t .F-'1F-'7-r---i
INSURANCE COVERAGE
I have a curent liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. '142 YES i110 7
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BO;;BELOW
LIABILITY INSURANCE POLICY (✓- OTHER TYPE INDEMNITY ! J BOND ❑
OWNER'S INSURANCE !r!�AIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
iViassachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OV'!NER ❑ 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 my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co piiance with all P^ i'nent p ovision of the
Massachusetts State Plumbing Code and Chapter .142 of the General Laws0,,,.,. /'V
PLUMBER-GASFITTER NAME I 1...z54cr- LtieLet6- j LICENSE :Lc}5(vdI SIGNATURE
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MP n IJGF LZ JP ❑ JGF ❑ LPG' El CORPORATION 04 PARTNERSHIP 114. , LLC #1"-- 1
COMPAI'IY NAME: CAp (.cc( .gz. LQ'i-f.- pmetoRREss 23 got-vete d-11 .
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CiTY MAL5iLile e., STATE ;�r'ZIP Oat, 'Li4 TELI50.S— f71_ s ?S 7
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