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HomeMy WebLinkAboutBLDG-21-003027 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W f JOBSITE ADDRESS 426 WEIR RD CITY YARMOUTH MA DATE November 27,202( PERMIT# OWNER'S NAME FORTI CHRISTINE A BLDG-21-003027 t G OWNER ADDRESS 92 BROOKINGS ST MEDFORD MA 02155-5407 TEL • TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 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 1 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 Michael Lafortune LICENSE# 1150 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' © CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MICHAEL Z LAFORTUNE ADDRESS. 300 OAK ST, CITY HARWICH STATE MA ZIP 026451940 TEL FAX CELL EMAIL 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 • ,r �� 1P0�l111! APPLICATION O PERMIT PERFORM FITTINGWORE ' � . ,r ' ce : r♦ Vñ2ft71 ) � MA DATE PERMIT# ( L ` '.. -.` / � JOBS1TE ADDRESS_ 1. ( - �;; O CR'S NAMEZ.--A121. el' if G . f { OWNER ADDRESS T`- L FAX CY CI EDUCATIONAL RESiDE��1TiAL i { TYPE OR • OCCUPANCY TYPE. CO"�1�iiER���.L � CLEARLY ' RENOVATION: El REPLACEMENT: ❑ PLANS SUBMITTED: YES 0; NO El NEW: 0 M_�� _.__�___.._- r - �; i 7 8 9 1�J 11 17 13 1 APPLIANCES FLOORS-'i' �� ys 1 I " - _ ,.� r BOILER ! -a---; i .. ( 1 . BOOSTER . .,� _.�-.�-. ' -----�-; _ , CONVERSION BURNER I, , i COOK STOVE + DIRECT VENT HEATER ---------r--, _ _.- -- --_-- .--o .— DRYER I . _ SS FIREPLACE i YOL4TOR i 1 —4--- 1 J_ - --- ---- i I i i 1 GENERATOR ! �.----- I ! +_____i_______ GF ILLE ,-- ' 1 j ; INFRARED HEATER i ► 1 - r. LABORATORY COCKS -T rr- �--- AKEUP AIR UNIT _�___ OVEN __ _ } POOL HEATER -- - ----.L--.T. TJi — . , . ROOM 1 SPACE HEATER - ROOF TOP UNIT ! ! t -_�- ---� - { UNIT' HEATER I i . -. !!,, , „,c, Lr- , „‘ , . _ _ • UNi�EN";'ED ROOM NESTER ! ` - ► t fi - --�.--j- i WATER HEATER - OTHER ' ! �. -" i I it) ► i I _,;_____ _ ,i 1 ___i_________t_r_ 1 1 . o. -- ..�r_.�__..._ INSU ,NCE COVERAGE current liability insurance policy or its substantial equivalent which meets t..he rcgf raments of MOL" Ch. 142 YES NO 1 ! "OLI CHECKED YES- PLEASE INDICATE THE TYPE OF COVERAGE SY CHECKING In APPROPRIATE BOX BELOW LIABILITY PO�IC`� INSURANCE OTHER TYPE INDEMNITY 0 BOND ° NCE WAIVER, 9 aln aware that :he " censaa c.1cas not have the insurance coverage required by Chapter 142 oft o Massachusetts'General Lis and that my signature on this p r :it application waives this roquirement. CHECK ONE ONLY: OWNER E AGENT 0 SIGNATURE OF OWNER OR AGENT hereby �_ e dQta. and intonation 1 have submitted cr ' Ittered ram; °ding this application are true and ac;u rats to the best of my knowledge certify fatth � n that all l �nbir work and installations performed under the permit issued for thi6 appl cation will be in compliant 'in 11 a snant r vision of the l`iias�clA;,s State Plumbing Code and Chapter 142 of the Genera; Laws. � ,L�� LICENSE # 11,� C� SIGNATURE PL U��BER-GasF1TrE�. NAI4�1E 1�"��� 1� � <��� �-; .. PARTNERSHIP � # LLC 0 # MP 0 MGF 0 JP 0 JGF Li LPG( 0 CORPORATION 0 { deX. 2 ?-....01 ", . COMPANY r NAME _ _ ADDRESS P- ! f ' ZIP D TEL���, 764 .� > 7_ STATE J e.__ _ CITY � .� D,e�y�U� �. 1�?/L�, - 3CE .L '� �/7�r7 _.__ EMAIL��, __ __..-.__.m._.. 4..................,..._......._........_,______