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HomeMy WebLinkAboutBLDG-21-006602 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1� CITY YARMOUTH MA DATE May 14,2021 PERMIT# BLDG 21-006602 1.s. JOBSITE ADDRESS 25 SACHEM PATH OWNER'S NAME nick demetriades G OWNER ADDRESS MA 02149-1443 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 Gregory Selfe LICENSE# 26714 SIGNATURE MP 0 MGF 0 JP El JGF 0 LPG] 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: GREGORY A SELFE ADDRESS. 41 SPRINGER LN, CITY WEST YARMOUTH STATE MA ZIP 026734930 TEL FAX CELL ( EMAIL I 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 WORK il =t!l. V++= � CITY � °,4 MA DATE s-t3 al PERMIT# 4(-p(' ZI-vo (x,oz. JOBSITE ADDRESS as SricAv-e o PA-t^ OWNER'S NAME H 1 `.k+2.7 ,vaA enie-4-ha4u GOWNER ADDRESS S 5 Ac-t) e 494 TiL!'60) 9 6"1•y 8 30 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL CFN PRINT CLEARLY NEW:. RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES El NO El APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE f 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES C2 NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY rid OTHER TYPE INDEMNITY El 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. CHECK ONE ONLY: OWNER ❑ AGENT El 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. �r PLUMBER-GASFITTER NAME 6ri3o LICENSE#a4.114 SIG ATURE MP❑ MGF El JP© JGF❑ LPG!El CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Gr"d°°`7 S`t re ?him A J CO ADDRESS j I 3/9 12.t n AP° 2 2- A-nt- CITY 1-1)' Ykrfa.v1IN STATE 1'r ZIP C146-73 TEL @-ba)) 1`Z -1 Y 3 9. FAX CELI1°€) I43 EMAIL ceIF•8(ea e y 4on.cm.r►-+ o