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HomeMy WebLinkAboutBLDG-22-005463 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tr—% `F CITY [YARMOUTH MA DATE March 29,2022 PERMIT# BLDG-22-005463 JOBSITE ADDRESS 915 WEST YARMOUTH RD OWNER'S NAME ENGARD JASON G OWNER ADDRESS 915 WEST YARMOUTH RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ 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 1 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 ❑ 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 Leon Hall LICENSE# 8782 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ILEON R HALL ADDRESS. 77 Hazel Ln, CITY Brewster STATE MA ZIP 026311729 TEL FAX 1 CELL EMAIL none 910N M31A32i NVId #11M3d $ 33d ❑ ❑ 11INIEd 3H1 SV S3Aii3S NOI LVOIlddV SIHl oN SOA S310N NO1103dSNI 1VNId AINO 3Sfl 210103dSNI HOd 30Vd SIHI S310N NO1103dSNI SVO HOflO! _ CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I 2 MA DATE Jr/ / Z PERMIT# JOBSITE ADCiRESS y/h CUESj Y L aT" RO OWNER'S NAME ,' 'm Oc'iv vcc:LY BUI 1 G DEPART MFNT BY __OW AD $iLjni- TEL <,/C3 1' 9 39c?,('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 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 INSURANCE COVERAGE I have a current Iiabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I NO .( I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' 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 Massa usetts General Laws,and that my signature on this permit application waives this requirement. �LZw1 CHECK ONE ONLY: OWNER . AGENT SIGNATURE OF OWNER OR APENT 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 alLPertinent ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER:NAME /€'0n Phi/WC/1 LICENSE# SIGNATURE MP \ MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: ADDRESS CITY STATE ZIP TEL 774/- 2 r-G&.2 Sir FAX CELL ? -1AisaliEMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE: $ PERMIT# PLAN REVIEW NOTES