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HomeMy WebLinkAboutBLDG-22-004202 #A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kOlCITY YARMOUTH MA DATE January 27,2022 PERMIT# BLDG-22-004202 JOBSITE ADDRESS 49 WILFIN RD 4 OWNER'S NAME GREGORY G NELSON G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El 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 1 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 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 GREGORY NELSON LICENSE# 12462 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: GREGORY G NELSON ADDRESS. 48 LUNAR AVE, CITY BRAINTREE STATE MA ZIP 02184 TEL L FAX CELL EMAIL S310N M31A321 NVld #lIWd3d $ :33d ❑ ❑ 111183d 3H1 Ski S3A213S NOI1k011ddV SIHI oN saA S310N NOI103dSNI 1VNId AlNO 3Sl 2i0103dSNI 2IOd 3OVd SIHI S31ON NO1103dSNI SVO Fiona'I liViMiP _:. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING � c',y' CITY ✓��,�rh r�v�'h MA DATE o� i/a ;'- PERMIT JOBSITE ADDRESS Y9'/e? Wi/L'c / i2 OWNER'S NAME 6R, D��ir — � Sa r7 III fr OWNER ADDRESS ",'' Lei 274,7eilt TEL / ` ' ~ 6/ F�y TYPE OR 7 G, PRINT OCCUPANCY TYPE COMMERCIAL 1 EDUCATIONAL ! i RESIDENTIAL !Lt CLEARLY NEW: ! 1 RENOVATION: L REPLACEMENT: L---- PLANS SUBMITTED: YES -. NO APPLIANCES _i FLOORS-+ BS1v1 1 p BOILER y 10 1.� 12 13 14 BOOSTER _ CONVERSION BURNER COOK STOVE J r / DIRECT VENT HEATER _ DRYER FIREPLACE -- FRYDLATOR FURNACE )1\ GENERATOR GRILLE ---� _ _� INFRARED HEATER I LABORATORY COCKS — MAKEUP AIR UNIT OVEN 1 POOL HEATER 1 R F7e,:;., F---77-71--ry.-4+ ROOM I SPACE HEATER ROOF TOP UNIT TEST IAN 2 5 22 - UNIT HEATER - UhdVEh �.._- I 1 ITED ROOM HEATER BUTLUl1VL 1__ t1-"kK1 N7E: WATER HEATER {3y - - - - OTHER - l - INSURANCE COVERAGE 1 } 1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of riIIGL. Ch. 142 YES _ NO P I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY 11 BOND 11 I OWNER'S INSURAI1 SCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the i Ma5sar_hu el:ts General Laws, and that my signature on this permit application tyfaive this requirement. )..„6117.., 3 _-NATURE OF OWNER OR, AGENT CHECK ONE ONLY: OWNER AGENT 7 -_, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the b `— and that all plumbing work and installations performed under the permit issued for this application will be in comp t pr li nce with all Pertinent e`r of my I,ovision o f the edge - Massachusetts State Plumbing Code and Chapter .142 of the General Laws. PLUMBER-GASFITTER NAME Geja yAi��sv� LICENSE # 10P (7ti 2 SIGNATURE MP I 1,(MC-;F I I JP [ JGF LPGI i-' -" -, CORPORATION li PARTNERSHIP E # LLC n # COMPANY NAME 6,07,,G y Ale /so /) ADDRESS ii i v CITY Bge7 .ii /ft< 1"( i' STATE /14 ZIP 1 U Da�� � TEL l/ � Zug y �74t (# FAX CELL (t7 VRi- 7 G(4- EMAIL 611 e is Q n u a IA Q wta: i_ . e 0 ar. . 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 1