HomeMy WebLinkAboutBLDG-21-006192 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�, CITY YARMOUTH MA DATE April 26,2021 PERMIT# BLDG-21-006192
JOBSITE ADDRESS 113 NOTTINGHAM DR OWNERS NAME STETKIS JON E
G OWNER ADDRESS 113 NOTTINGHAM DR YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0
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
INFRARED HEATER
LABORATORY COCKS .
MAKEUP AIR UNIT ,
OVEN .
POOL HEATER 1 .
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1
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 0
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 John Downey LICENSE# 32070 SIGNATURE
MP 0 MGF 0 JP E] JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑#
COMPANY NAME: ADDRESS. 37 Bray Farm Rd.N,
CITY Yarmouth Port STATE MA ZIP 02675 TEL 5082215257
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ El
FEE:$ PERMIT#
PLAN REVIEW NOTES