Loading...
HomeMy WebLinkAboutBLDG-23-003973 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tb CITY YARMOUTH MA DATE January 20,2023 PERMIT# BLDG-23-003973 JOBSITE ADDRESS 379 WEIR RD OWNERS NAME KARRAS STEVEN J TRS G OWNER ADDRESS KARRAS CHERYL A TRS 379 WEIR RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ 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 1 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/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❑ 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 Ronald Nurse LICENSE# 13397 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RONALD W NURSE ADDRESS. 221 COTUIT RD, CITY SANDWICH STATE MA ZIP 025632655 TEL FAX CELL EMAIL ptech88ta7.amail.com 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 "'` 'Et CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK nr= • • . CITY �i i. .► Uc1 •MA DATE 1 Ls.—J:3 PERMIT# Z.� . 2 73 I. N 19 ghg ' 7 tr lJ E, DO .ESS .3 � (,� e OWNER'S NAME 'K«v( c B G D ItMOdl - DiD•ESS TEL FAX 1'P1 Ott OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL PRINT ❑ RESIDENTIAL CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ SUBMITTED:: YES'ES❑ NO ❑ ; APPLIANCES FLOORS BSM 1 BOILER ` 2 3 4 5 6 9 10 1'I 12 13 1". I BOOSTER ~� i CONVERSION BURNERI I COOK STOVE DIRECT VENT HEATER DRYER __ FIREPLACE I FRYOLATOR FURNACE I GENERATOR GRILLE - J INFRARED HEATER -- LABORATORY COCKS __a MAKEUP AIR UNIT __-_ OVEN • POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST __ UNIT HEATER r UNVENTED ROOM HEATER J WATER HEATER I OTHER . I I 1 c I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.1142 YES X 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 a i o the best of my wledge and that all plumbing work and installations performed under the permit issued for this application will be in comp]' a with all Pertinent prove the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# 1W SIGNATURE MP N MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME \Ut c z.J LA J/LV Ch ��.c `pq.) ADDRESS 6 .i lti3 CO--- __ CITY 5 cw-S.I.A) (AL, STATE iikril ZIP 563 TEL 5c)6_ LiJ 644 FAX CELL EMAIL h49_ b LA0.:\-4, (U w.- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Ye5 No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES 1