Loading...
HomeMy WebLinkAboutBLDG-22-001805 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK z k ff �/ CITY YARMOUTH MA DATE September 29,202 PERMIT# BLDG-22 001805 JOBSITE ADDRESS 86 NIGHTINGALE DR OWNER'S NAME Brent White G OWNER ADDRESS 86 NIGHTINGALE DR SOUTH YARMOUTH MA 02664 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 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 0 OTHER OF 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 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP [026735706 TEL FAX CELL EMAIL halloilcompany(cilgmail.com - S310N M3IA3b NVld #1I V Jd $:333 ❑ ❑ 1I11213d 3H1 SV S3A 13S NOLLVOIlddV SIHl oN saA S310N NOI103dSNI 1VNId )llNO 3Sf JO103dSNI JOd 39Vd SIH1 S310N NOI103dSNI SVO HJnOZI MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ;!l a %I1t1(Nb YM,vtotrTll MA DATE /' 2 ' 201 PERMIT# SEP /62i DCREIS N IAA N t6 DIa i OWNER'S NAMET��J� k)1�i� OWNER_ADDREStS8Co N14K'ti Ai& J� 77/0 33 FAX TY It_i]iNG DEPARTMENT E COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALI►_/ CLEARLY NEWX RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ `" \ APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE ¢� FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. ' CHECK ONE • -Y. 1W ER ►! AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application e true a • -cc , to e best• my knowledge and that all plumbing work and installations performed under the permit issued for this application will be' comp!', P inent• . ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME f 1 LICENSE# " �1 SIGNATURE MP�J MGF❑ JP❑ JGF❑ LP I ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME 'AN )1U 3 --141 /'T ADDRESS � Il tO CITY jr STATE ZIP c4..627 3 TE5 `"77(o- 7�$ FAX CELL EMAIL 0yST&L I I L ( — aI.(c e 1 co,-v 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