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Home My WebLink AboutBLDG-22-000065 - . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE July 06,2021 PERMIT# BLDG 22-000065 k,, I JOBSITE ADDRESS 21 VESPER LN OWNER'S NAME HOPKINS NANCY M G OWNER ADDRESS 21 VESPER LN YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO ❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 I 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 1 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 El 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 William Holmes LICENSE# 3942 SIGNATURE MP❑ MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: WILLIAM B HOLMES ADDRESS. 9 HUNTERS TRL, CITY SANDWICH STATE MA ZIP 025632701 TEL FAX I I CELL I I EMAIL 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 ..,y \ �: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 `',ter-'o ac, y�lZ Z -o OO(o r `:��:�, CITY �0 V��D 0-- MA DATE 7- ID � �' � PERMIT � Qt�D ( - ,G?yam=r,.. 1 JOBSITE ADDRESS a ) Yes 1 et- I-Ane- OWNER'S NAME I41:019/(1 hs OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: f PLANS SUBMITTED: YES ❑ I\1(err APPLIANCES 1 FLOORS-- BEM 1 2 3 4 5 6 78 9 10 '11 12 13 1 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I DRYER FIREPLACE 1 FRYOLATOR 1 _ FURNACE E c E i V E Q I GENERATOR 1 _ , ....._'�_ J GRILLE _ INFRARED HEATEF. RI 0 € � LABORATORY COCKS _ T. _ i MAKEUP AIR UNIT B�JILDIN _G DEPARTMENT — I OVEN ---1-_ —i POOL HEATER ROOM ! SPACE HEATER. ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or it substantial equivalent which meets the requirements of IMGL. Oh. 142 YES.O ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I • OWNER'S INSURAI4CE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the I Massachusetts General Laws, and that my signature on thispermit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1 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 I `; 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 4, Massachusetts State Plumbing Code and Chapter *142 of the General Laws. tN) 4j PLUMBER-GASFITTER NAME B ) 1 , LICENSE # 39 9 }- SIGNATURE MP ❑ PAGF ❑ JP ❑ JGF 2rLPG1 7 CORPORATION 0 If PARTNERSHIP ❑ # LLC ❑ # �y lie S CIS+fi 41—irk ) \ COMPANY NAME 8y f'r1 � o Irf‘c-C ADDRESS l CITY So0A1/40` STATE ANA- ZIP 0 S b Z TEL FAX CELL EMAIL g IN0 hiNcr' a-""� 0 Gt hut• I co 1v j .-- --(5-1---- c V.44kk°39 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 •