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Home My WebLink AboutBLDG-22-001672 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kiCITY YARMOUTH MA DATE September 23,202 PERMIT# BLDG-22-001672 JOBSITE ADDRESS 16 WEIR RD OWNER'S NAME DEXTER JEFFERSON S TRS G OWNER ADDRESS DEXTER DINA G TRS 16 WEIR RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: 0 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 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 1 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 El OTHER OF INDEMNITY❑ BOND El 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 LICENSE# 34056 SIGNATURE MP❑ MGF ❑ JP El JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: THEO PLUMBING AND HEATING LLC ADDRESS. P.O.Box 397,P.O.Box 397 CITY Centerville STATE MA ZIP 02632 TEL FAX CELL EMAIL theoplumbino(@,yahoo.com S31ON M31f321 NVId #110183d $:33d ❑ ❑ 1I11H3d 3H1 SV S3A2:13S NOIlVOIlddv SIHl oN saA S31ON N01103dSNI 1VN13 AINO 3Sfl 80103dSN1 aOd 3OVd SIH1 S31ON NO1103dSN1 SVO Hel0?J `, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK li:� t ,e- CITY e41 'i-Tre-:--.7S4 q �'^ (po - i MA DATE ( 22 ( z 1 PERMIT # 2.l 14'"7 Z_ JOBSITE ADDRESS ( C Le L R--Do•tJ OWNER'S NAME Tece'c — (Peer i— OWNER ADDRESS l Co C) e-IV kO Ad TEL CPt CABS 6O FAX TYPE PE OCCUPANCY TYPE COMMERCIAL ❑ EDUPATIONAL ❑ RESIDENTIAL ES1-/ PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES 4 FLOORS--4. MIA 1 2 3 4 5 6 7 ° 9 10 11 12 13 14 BOILER BOOSTER — 1 CONVERSION BURNER — COOK STOVE DIRECT VENT HEATER i DRYER FIREPLACE j FRYC)LATOR _—M . FURNACE i' GENERATOR ( I .;' � �N _ • � GRILLE INFRARED HEATER 7,_,-2 ' t 1 LABORATORY COCKS i MAKEUP AIR UNITfJ; .;; OVEN ‘Looly.,-1. - POOL HEATER ROOM / SPACE HEATER ROC)F TOP UNIT _ TEST _ . _.._ 7UNIT HEATER UI'4VENTED ROOM HEATER WATER H EA1 E R .1 OTHER i 1 I Ell INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL• Ch. 142 YES "L NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE GE 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 i Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 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 accurate to the best of my knowledge _ ti 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. Z J PLUMBER-GASFITTER NAM = LICENSE # SIGNATURE MP ❑ MGF ❑ JP JGF ❑ LPGI ❑ CORPORATION ❑ li PARTNERSHIP ❑ 41 LLC IUl it n ff __ P,kCl� pc: ; 3ae,<ga COMPANY NAME 7 et) 10 I v�--t9 \ +e4DDS fG 6 c i - CITY C Pv--'rc,/✓ .1 (e. STATE I i ZIP G2 6 '3 ? TEL C6C6 -3 36- FAX CELL EMAIL A--- ,-2-e i/��...) +�'`.� l4- ,^ a �--�Ct) .C d',Z ,/ uu ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL IINSPEC TIO1 d NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES