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Home My WebLink AboutBLDG-23-003473 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .�, CITY YARMOUTH MA DATE December 23,202; PERMIT# BLDG 23 003473 fi JOBSITE ADDRESS 12 NICHOLAS DR OWNER'S NAME SEMINARA LOUIS J III G OWNER ADDRESS SEMINARA JESSICA A BOX 450 S DENNIS MA 02660 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 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 0 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 John Smith LICENSE# 32777 SIGNATURE MP❑ MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JOHN G SMITH ADDRESS. 24 SANDY LN, CITY HARWICH STATE MA ZIP 026452004 TEL FAX CELL EMAIL iohnsmithplumbing1[?a.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 WORK WAT t ;I-f " CITY i kirrniqtAlf MA DATE 6-11Z'2.., PERMIT# JOBSITE ADDRESS 11 Vat/t01AS Cr, OWNER'S NAME L,na (rri. ��u�n�r► OWNER ADDRESS TEL S X .�d y 9Iq� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Vt., PRINT CLEARLY NEW:131. RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 0 APPLIANCES FLOORS-I SSM 1 2 3 1 5 6 7 8 9 10 11 12 •13 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER L_ DRYER L_ FIREPLACE FRYOLATOR I —~ FURNACE —� GENERATOR X GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN _ _ L__ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST . .__ . . . . . . . ._ ....... .. . UNIT HEATER _ INVENTED ROOM HEATER WATER HEATER OTHER L ___ • INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 50 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT "I• 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 LICENSE# 1,-7-- SIGNATURE MP 0 MGF 0 JP JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME-10\114 SMt� Cn f‘u,lhfi�ll6i ADDRESS ��I—rnvtr�a'{L✓1 CITY k H(v✓ltkl dt JJ STATE A- ZIP (91(f TEL 71 FAX CELL EMAIL —I t'11nh , 4nml+liY.ilt Q l��M/lill'l ,(/ '..--- 4 1 I I GI G I 1 V 1 r I iI I . i I 1 i • I I ; z❑ G M W ° E❑ rr, I v-i 1 0 w I I - I ;- . �C lu. . > .. . O a I rs. � 4 O Q. I CS FM °— a_ < (>3 crs 1 I— _ I lip 1 Cl CO 1 1