HomeMy WebLinkAboutBLDG-22-004006 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
>N= CITY YARMOUTH MA DATE January 20,2022 PERMIT# BLDG-22-004006
JOBSITE ADDRESS 1 UNCLE JIMMYS LN OWNER'S NAME Dale Cook
G OWNER ADDRESS 1 UNCLE JIMMYS LN YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ 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
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR 1
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I 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 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
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 Mark Moran LICENSE# 20786 SIGNATURE
MP❑MGF❑JP El JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑#I ILLC 0#
COMPANY NAME: MARK R MORAN ADDRESS. 16 BRAMBLE BUSH DR,
CITY FORESTDALE STATE MA ZIP 026441017 TEL
FAX 17 CELL EMAIL
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- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS f' /4 OWNER'S NAME/� �.4G
OWNER ADDRESS TEL
FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 07-
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 i 5 5
BOILER o 9 10 11 12 13 L1
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER �_�___.
DRYER
FIREPLACE
FRYOLATOR :—
FURNACE ,
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS .._____I___________„—_____-
MAKEUP AIR UNIT •
OVEN
POOL HEATER
•
ROOM/SPACE HEATER _______IROOF TOP UNITI
—`—
TEST
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER ' ______r___
OTHER
1
INSURANCE COVERAGE
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Rio
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW O
•
LIABILITY INSURANCE POLICY M./ 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,
SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER ❑ AGENT ❑
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac r to 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 • II Pertin t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAMES/4 AOd/i LICENSE# "` ��1
SIG ATURE
1,
MP ❑ MGF❑ JP 1VJGF❑ LPG! ❑ �>
'ORPURATIOIV ❑tF PARTNERSHIP lc it LLC❑it
COMPANY NAME ir4`4 r"---72/ ADDRESS , / ✓.y��'�
,\
CITY / -Th� 1Q STATE �ZIP C
TEL
FAX CELL
EMAIL G
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ROUGH THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
PEE: PERMIT #
PLAN REVIEW NOTES