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HomeMy WebLinkAboutBLDG-18-001792 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Zerf CITY YARMOUTH MA DATE September 27,201 PERMIT# BLDG-18-001792 JOBSITE ADDRESS 858 WEST YARMOUTH RD OWNER'S NAME NEIER DENNIS S G OWNER ADDRESS KRUPKIN MARISHA E 150 EAST 77TH ST NEW YORK NY 10075 TEL TYPE OR OCCUPANCY TYPE • COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 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 ❑ 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 LESTER WADE LICENSE# 4569 SIGNATURE MP 0 MGF © JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD, CITY ICOTUIT STATE MA ZIP 026352702 TEL FAX CELL 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 `400.41 �= crrY ,� MA DATE ..•.qj -�I Iir ...__..� PERMIT # 3 -If-oo I g JOBSITE ADDRESS • • &YVV� O'�t` '�11-r/ � QWNER'S NAME GC _.„ _ GOWNER ADDRESS 1 -- et.."./4., ___, __,. _. ._. I TEL I 1517 Sc-111 - Jf . I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 6 PRINT CLEARLY NEvV: I� RENOVATION: REPLACEMENT: : , . PLANS SUBMITTED: YES NO I. APPLIANCES -1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER a i BOOSTER ' ___I _ CONVERSION BURNER COOK STOVE : _ ' . -7--- -- Th— - '- ---r . _ ., _ _ — I DIRECT VENT HEATER DRYER 1111W 111111Willi10111111191111111.1111.1111 FIREPLACEf -1111 alleNliiiiiillfitlita FRYOLATOR 1.1111111111 - 1.11111.11111111111111M11111110.1.1 11111111.• FURNACE IN': ' � �..� _ GENERATOR I ' GRILLE - INFRARED HEATER O -_ _ IMO M LABORATORY COCKS T= MAKEUP AIR UNIT ( � I- . 1 11.1 OVEN I _.POOL HEATER I ._,-^ � - r— - 1.1 ROOM / SPACE HEATER ��' z.. 1L ROOF TOP UNIT ffiliiiill __., �. TEST __._ ini iiiiimil UNIT HEATER —� _ i P I V ___� , IIIttI UNVENTED ROOM HEATER { 1111. 11011001011111111111W :-_--- WATER HEATER ' OTHER j __ _. ir _ INSURANCE COVERAGE substantial equivalent which meets the requirements of MGL. Ch. 142 YES IVI NO Li I have a current Iiabilit,Llnsurance policy or its q I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V 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 my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i 1 � r PLUMBER-GASFITTJR NAME Lectr VVtli LICENSE #136- -t SIGNATURE MP MGF JP L i JGF ❑ LPGI 0 CORPORATION L # 1-7--' PARTNERSHIP TI#[ - LLC (I# - - , COMPANY NAME: OtiRESS g- 6e3 a t1'i CITY STATE r ZIP t-t lot 'TEL OW-.OT FAX 1 CELLI 51)4?" -- EMAIL r} Prcje I t- - 7