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HomeMy WebLinkAboutBLDG-21-001008 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "' wl • CITY YARMOUTH MA DATE August 27,2020 PERMIT# BLDG-21-001008 JOBSITE ADDRESS 15 NORTH COVE LANDING OWNER'S NAME ANNINO BETH L G OWNER ADDRESS 151 TREMONT ST MANSFIELD MA 02048 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO El FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER 1 FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 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 El 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 Joseph Lemieux LICENSE# 10791 SIGNATURE MP 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: Joseph S Lemieux ADDRESS. 18 DINAHS WAY, CITY WAREHAM STATE MA ZIP 025711463 TEL jD J 7- FAX CELL EMAIL wir ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIOINOTES Yes No THIS APPLICATION SERVES AS THE PERMIT CI ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •.,-`.— CITY /�G�ill MP DATE PER JOBSITE ADDRESS 1 ( e/��� OWNER'S NAME n/�'t0 GOWNER ADDRESS /$7 ,JIN f1I r/�` /1/.4 'r'ITEL - A,9'FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIO JAL 0 RESIDENTIAL((�••-•"------- PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMI I I tU: YES❑ NO 0 APPLIANCES-1 FLOORS-* 9SM 1 2 3 4 5 6 8 9 10 11 12 13 t-'. BOILER - / BOOSTER CONVERSION BURNER COOK STOVE J _ DIRECT VENT HEATER DRYER FIREPLACE / _ 1 FPYGLATOR FURNACE _ ,_ GENERATOR GRILLE t 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 i INSURANCE COVERAGE - � � I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ldlo LJ X I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 Ne Massachusetts General Laws,and that my signature on this permit application waives this requirement. J CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are a to of my knew ledge and that all plumbing work and installations performed under the permit issued for this application wilt be in pli provision of the '' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-G ITfERNAME UCENSE#/0/9/ SIGNATU MP MGF 0 JP❑ JGF❑ LPG!0 CORPORATION 0# PARTNERSHIP 0# t.Lc 0# n COMPANY NAME — r-S.- ).e44.4-i . 4 a,S ADDRESS U" a ?d, I i%_ CITY/L `.),,,,�4 o i\- STATE G/i0` ZIP 03C� TEI�O7 —err/�,)> / �3d ;5., lS -Cot FAX CELL6I1 —�(� - 4 EMAIL lei"-SA - . • 1- Si• • m m = cn o y m � w C m ,. • . rsi a 48 as ar sr t" vi 4 O ,n