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HomeMy WebLinkAboutBLDG-22-004373 i - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 07,2022 PERMIT# BLDG-22-004373 JOBSITE ADDRESS 10 NAUSET RD OWNER'S NAME Andy Silva G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ 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 1 DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 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 CI 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 Forrest Ferrill LICENSE# 9964 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: FORREST A FERRILL ADDRESS. 10 ORCHARD WAY, CITY SANDWICH STATE MA ZIP 025632555 TEL FAX CELL EMAIL forrest(aafrogmendivers.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 P FORM GAS FITTING WORK k` , ` CITY '/,"9 M G L R MA DATE c�..---7" a PERMIT# JOBSITE ADDRESS I 0 N U�. L-� �� OWNER'S NAME 1 T1vdy , / V4 GOWNER ADDRESS 5 Q._. TEL 5 b$ 615 CB CIS—FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALk PRINT CLEARLY NEW:❑ RENOVATION: kl REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 21 APPLIANCES 1 FLOORS-4 BSM 1 2 3 1 5 6 7 8 9 10 11 12 13 Lii BOILER I BOOSTER —_' CONVERSION BURNER -- COOK STOVE I _— DIRECT VENT HEATER DRYER _3._ FIREPLACE FRYOLATOR �— FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN L � POOL HEATER • . ROOM I SPACE HEATER ' ROOF TOP UNIT TEST . . ....._.. -- --- UNIT HEATER INVENTED ROOM HEATER 1 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 cli OTHER TYPE INDEMNITY ❑ BOND ❑ 1 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 ❑ 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 befit I: owledge `, and that all plumbing work and installations performed under the permit issued for this application will be in compf nce with all Pertinent pro i n f the �`Li) Massachusetts State Plumbing Code and Chapter 142 of the General Laws. &Af, ,�� PLUMBER-GASFITTER NAME LICENSE# op y .IGNATURE MP NI MGF E JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME 61-- ��+/r/ / ADDRESS /0 01` AnA W CI CITY Pt&LOW1 U STATE-ik- ZIP b`?-/-.. J-7j TEL �j D c6 c- O VD FAX CELL EMAIL -0(y-e_437- COEFIA ENO jOei1 f /L • " V I 4 G • I I G • ul t z- • . �• . Q 2 F, Q 6} U} I I- IU I Go G I 04 i