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Home My WebLink AboutBLDG-23-005192 -I - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 21,2023 PERMIT# BLDG-23-005192 JOBSITE ADDRESS 13 WALTHAM CIR OWNER'S NAME HOLLINGSWORTH BENJAMIN ERIC G OWNER ADDRESS HOLLINGSWORTH B J&WM&J CAHILL 13 WALTHAM CIR WEST YARMOUTH MA TEL 02673 TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NC) ❑ 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 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 Daniel Smith LICENSE# 34996 SIGNATURE MP El MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#17-I COMPANY NAME: ADDRESS. 79 East Osterville Dr, CITY Osterville STATE MA ZIP 02655 TEL FAX CELL 8578809696 EMAIL DANIELL12plumber@,,GMAIL.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 .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING W0 RK 04:V IA y41Z-MOLYCli MA DATE 3-2.1 - �.3 -• PERMIT MA 1 20 3i OSITE ADDRESS 1`1, v.),AL tkP,M Kcu Cz OWNER'S NAME O4EPADDRESS ,, WI iG I-lb))'Irii�(dH TEL BB L� ENT 9 K M FAX er._--� U r UPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDEIJTIALA CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENTS PLANS SUBMITTED: YES❑ NO❑ APPLIANCES T FLOORS-4 6SM 1 2 3 4 5 s BOILER s 9 10 11 12 t; :R BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN i i • POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT t TEST - . UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0- 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT El • 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 PlumbinL•IJg Code and Chapter 1.42 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# P1..3Lf 59 -3 SIGNATURE MP❑ MGF 0 JP 13 JGF❑ LPG! ❑ CORPORATION 0 4 PARTNERSHIP❑# LLC❑# COMPANY NAME D-C S PLvltia0u6- ADDRESS 75 CKSC 0 l' .i2Vtl`(7-- 9.9 CITY 6Sr€1 I.F STATE lin A- ZIP G2-(--0 55 TEL $5 7 av - 5 cp 5 Cp FAX CELL EMAIL Div,tit c.Q \.,Qta1q-j6(L c),Cfi/t'1 _- C.aM I I Gl H o 1 I I U w I Gr1 7 w I M7 i 44 I I I 1 1 I I I ti I w W� ID VII y F� G w 0 a I VA = I I-- .. rc tu. w a > z w � a 1 w CD v 0. I r a. a. En ui r I.I- ,I 1 W I k IG I 1 I MN n r 0 I, I