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HomeMy WebLinkAboutBLDG-22-004205 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH .1 MA DATE January 27,2022 PERMIT# BLDG-22-004205 • JOBSITE ADDRESS 49 WILFIN RD 1 OWNER'S NAME GREGORY G NELSON G OWNER ADDRESS 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 1 GENERATOR GRILLE 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 El 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 he 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 ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: !GREGORY G NELSON ADDRESS. 48 LUNAR AVE, CITY BRAINTREE STATE MA ZIP 02184 TEL FAX 1 CELL EMAIL S310N M31A3H NVId #1IIN2i3d $ 333 ❑ ❑ 111%13d 3H1 SV S3Aa3S NOI1V3IlddV SIHI oN saA S310N NO1133dSNI 1VNl3 AlNO 3Sfl a0103dSNI 2103 3OVd SIH1 S310N N01133dSNI SVO HOflOa iiiiASSACNUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t -;41 CITY yetem a Liii, MA DATE �/ ' off- PERMITJOBSITE ADDRESS ve, 0 WI I F111 12-p OWNER'S NAME i#4..G OWNER ADDRESS y8 L L,,.,yit 4-cle— / —7 TEL 7 ya c FAX TYPE OR Gi �/.[ PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q---- CLEARLY NEW.❑ RENOVATION: ❑ REPLACEMENT: [------- PLANS SUBMITTED: YES❑ NO❑ APPLIANCES T FLOORS BSIu1 11 ? 3 5 6 7 BOILER 9 10 1I 12 1=— 14 BOOSTER — CONVERSION BURNER COOK STOVE r — DIRECT VENT HEATER DRYER �i FIREPLACE FRYC)LATOR FURNACE - GENERATOR GRILLE INFRARED HEATER i LABOPJATORY COCKS — MAKEUP AIR UNIT • R P OVEN VF POOL HEATER7 f ( I ROOM!SPACE HEATER I 1._ Jr yl�z ROOF TOP UNIT �U TEST Buu ram. . (3y rtif.21 UNIT HEATER -- MAN, UNVENTED ROOM HEATER —_H WATER HEATER OTHER > > INSURANCE COVERAGE I have a current iiat)ili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ 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 • Masvach setts General Laws,and that my signature on this permit application waives this requirement, l I CHECK ONE ONLY: OWNER 0- ENT n . IGNATURE OF OWNER OR AGENT .t•. 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 comp' nee with all Pertinent provision of the �' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `1 PLUMBER-GASFITTER NAME GRe4 D/1 y /"�/� I s°I7 LICENSE# /a Y4 SIGNATURE MP r GF❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION 0 ► PARTNERSHIP 0# LLC COMPANY NAME ❑ ADDRESS t 4.),74 41./4_ CITY e� STATE/1 4 ZIP o 2//Y / / TEL !7 ,���-7w_ FAX CELLltl7 �/ y� 7y� EMAIL ISa�RlA1Zg 011i 1,,e 6.�- ' c Li RQUG G� 1NSIE—DEC QN I4PI F�3 !�S Q ONLY FINAL INSPECTION NOTES Yes NQ THIS APPLICATION SERVES PS THE PERMIT FEE: $ PERMIT _ PLAN REVIEW NOTES ,,;,*COMMONWEALTH OF MASS.ACHUSETTS, DIVISION OF PROFESSIONAL LICENSURE PLUMBERS AND GASFITTERS ISSUES,THE FOLLOWING LICENSE MASTER PLUMBER • G.IEGORY G NELSON 48 LUNAR.AVE BRAINT# I ,MA 02184-6963 12462 05/01/2022 856846 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER