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HomeMy WebLinkAboutBLDG-23-003693 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK * °171' r' CITY YARMOUTH MA DATE January 06,2023 PERMIT# BLDG-23-003693 JOBSITE ADDRESS 189 CENTER ST OWNER'S NAME HILLIARD HUGH C G OWNER ADDRESS HILLIARD JEAN S PO BOX 113 YARMOUTH PORT MA 02675-0113 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL 0 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO FIXTURES FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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/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 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 TYNDALL&CLARK CLARK LICENSE# Massachusetts SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: TC TYNDALL&CLARK ADDRESS. 18 ATLANTIC AVE, CITY SOUTH DENNIS STATE MA ZIP 026600000 TEL 5083858868 FAX CELL =EMAIL 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 PLUMBING WORK ' -��—�-,,"��= CITY 1'C r m o l h MA DATE 12 ® 2 3 PERMIT*,SLf)�'Z 3'//1�3 {= n JOBSITE ADDRESS / (.4 9 C..e u1'l P,& st, OWNER'S NAME S-{-eve Ca rb o1 a r0 POWNER ADDRESS S 4 L TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:ip, RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 6' 9 10 11 12 13 14 BATHTUB _ _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM —~ , DEDICATED GAS/OILISAND SYSTEM _ _ DEDICATED GREASE SYSTEM • DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ 0 DISHWASHER • V DRINKING FOUNTAIN L,• FOOD DISPOSER , FLOOR I AREA DRAIN _ INTERCEPTOR(INTERIOR) KITCHEN SINK 1, _ _ - 3 I LAVATORY I ?Lir ROOF DRAIN , I SHOWER STALL I / • _ - I SERVICE I MOP SINK I ( TOILET 1 i 1 URINAL ECEIVED co WASHING MACHINE CONNECTION 5 - - - -- ! WATER HEATER ALL TYPES I 5 1 WATER PIPING Fe 21 j OTHER p U't"S I U 1 5 l-Fow E Q 1 - _. ci_UILDI G DE PARISIFNT_ © Ey CO j INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 d IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 OTHER TYPE 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 e Massachusetts General Laws,and that my signature on this permit ap?lication waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT L1 t 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 al Pertinen rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Q PLUMBER'S NAME tra d I nt,e rass;n. LICENSE# 2 1 tp 9 4i SIGNATURE MP❑ JP❑ C RPORATION❑# PARTNERSHIP 0# LLCR1# COMPANY NAME h ,V 10 r ADDRESS 3 7 Z 5 g ' CITY STATE ZIP TEL 3`�' — 328 FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ o- PERMIT# .i PLAN REVIEW NOTES