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Home My WebLink AboutBLDG-22-005992 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4„1 It CITY YARMOUTH MA DATE April 19,2022 PERMIT# BLDG-22-005992 JOBSITE ADDRESS 43 COGSWELL PATH OWNER'S NAME Deb Person G OWNER ADDRESS 43 COGSWELL PATH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: m 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 1 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 Matthew Needham LICENSE# 5014 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Matthew J Needham ADDRESS. PO Box 561, CITY Centerville STATE MA ZIP 026320561 TEL FAX CELL EMAIL S310N M31A321 NV-Id #1II10:13d $:33d ❑ ❑ i1W1:13d 3H1 SV S3A213S NOIlV3IlddV SIH1 oN saA S310N NO1103dSNI 1VNI AINO 3Sfl 210103dSNI?J0d 30Vd SIH1 S310N NO1103dSNI SVO H9f1021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ii_ j E' Y4,re7ePviI �C/ .Net � - 1 h�i.�, �l I/1q �� PERMIT I' �'z- 5�15'2 ii_ 1 y �22BSE ADDRESS cj3 �o9s KDATE OWNER'S NAME s FAX r GWIJ�A DRESS TEL Y, :U(IC`�4fPE 0R P R r = T __ s-- v .AP CY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW. RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 NO❑ APPLIANCES 1 FLOORS- 8 M BOILER t2 3 A 5 I 6 7 ? 9 10 11 12 L 13 L BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER J —j FIREPLACE J _ --1`— FRYCiLATOR ` FURNACE GENERATOR GRILLE INFRARED HEATER _ LABORATORY COCKS MAKEUP AIR UNIT ___________ OVEN - - _ _ POOL HEATER _�— • ROOM I SPACE HEATER ROOF TOP UNIT ' , TEST - UNIT HEATER INVENTED ROOM HEATER - _ �— WATER HEATER OTHER 1 INSURANCE COVERAGE I have a current Iiabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESXNO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 15r OTHER TYPE INDEMNITY 0 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 CHECK ONE ONLY: OWNER 11 AGENT 0 ` 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 and that all plumbing work and installations performed under the permit issued for this application will be in complian ith all Perti a provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Li) PLUMBER-GASFITTER NAME 64-4-/ >ec(j 4-/i'l LICENSE# S�� NATURE MP ❑ MGF❑ //''J''P ❑�� JGF N. LPGI ❑ CORPOI CATION❑# PA.,,TNERSHIP❑# LLC❑# COMPANY NAME �� ,e ,� s �f'£4s' ADDRESS t°-89 �p ( CITY6 /c:E iv llW-f SSTATE/2IA ZIP °RC,cj,� �,/ TEL FAX CELL/2 c - CVO EMAIL Off„,2c1/ 44,,Jds' ,,1 -r i ----- ROUGH GAS i SFECI'1�I'( IfO` 'ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: PERMIT tt PLAN REVIEW NOTES