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HomeMy WebLinkAboutBLDG-21-005473 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 23,2021 PERMIT# BLDG-21-005473 JOBSITE ADDRESS 10 FAIRWOOD RD OWNERS NAME COTTER WINIFRED N G OWNER ADDRESS 10 FAIRWOOD RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 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 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 ❑ 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 Daniel Braley LICENSE# 26328 SIGNATURE MP 0 MGF ❑ JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DANIEL C BRALEY ADDRESS. PO BOX 878, CITY MONUMENT BCH STATE MA ZIP 025530878 TEL FAX CELL EMAIL PJMC007@a,HOTMAIL.COM ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE:$ PERMIT# PLAN REVIEW NOTES _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �"- ai LDP- 2c-O '(?3 • CITY: ►�R 1"'I 0 L�T H MA. DATE 3`)�' PERMIT# JOBSITE ADDRESS: r 0 F A.r i W o a 14 R�• OWNER'S NAME W i N'f R E a C-o TT E R 1 G OWNER ADDRESS: TEL: FAX: . TYPE 01t P�,r OCCUPANCY TYPE: COMMERCIAL 0 . EDUCATIONAL ElRESIDENTIAL ICLEARLY NEW:❑ RENOVATION:(" REPLACEMENT:❑ PLANS SUBMITTED: YES C] NO❑ 'L APPLIANCESZ FLOOR-0 Brant 1 2 3 4 5 6 J . 8 9 10 11 12 13 —14 BOILER • ( BOOSTER _ _ CONVERSION BURNER _ IT o COOK STOVE 1 a DIRECT VENT HEATER DRYER _ . v FIREPLACE t FRYOLATOR •-1 FURNACE GENERATOR ,,, GRILLE w kii 'INFRARED HEATER 1,43 LABORATORY COCK _ kMAKEUP AIR UNIT _ C) OVEN _ ... , POOL HEATER ROOM/SPACE HEATER _ 1 ROOF TOP UAVI'T t TEST _ _ Z UNIT HEATER t,U UNVENTED ROOM HEATER • WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES O 0 if you have checked/5,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Q 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby cerfy 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 tNs application will be In compliance with all Pertinent provision provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. Win- B tZA -e-a z(c3 Z$ .„-- de.--- PLUMBER/GASFITTER NAME LICENSE#{'444-8 - SIGNATURE COMPANY NAME: M 'r=H-,4AI PIA s HTEr ADDRESS: P•0• uo, 3 S8'33 CITY: goStiaIN) STATE: wtvt ZIP: 6)-13r FAX: TEL: CELL:SO$-2 41-cir4 o EMAIL (3 1`I r`.C Oil' ( ho�u.-la4( c MASTER lURNEYMAN❑ LP INSTALLER❑ CORPORATION El# PARTNERSHIP 0# LLC❑ii 0 c°� m I rn I rn ❑o