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HomeMy WebLinkAboutBLDG-21-007330 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kr9 CITY YARMOUTH MA DATE June 16,2021 PERMIT# BLDG-21-007330 JOBSITE ADDRESS 5 CEDAR ST OWNER'S NAME adam tate G OWNER ADDRESS MA 01803 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 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 1 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 El 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 Leon Hall LICENSE# 8782 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: LEON R HALL ADDRESS. 77 Hazel Ln, CITY Brewster STATE MA ZIP 026311729 TEL FAX CELL EMAIL none 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 �• -- CITY Y/9W/NDID7g MA DATE 1'/' /a1 PERMIT fr ai-b 6-/-k-out 33 JOBSITE ADDRESS C C Z34I gT 9, YIP OWNER'S NAME l lF G OWNER ADDRESS n Ic/-5z 'V FAX TYPE OR PRINTOCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL fir CLEARLY NEW:0 RENOVATION: REPLACEMENT:0 PLANS SUBMI i i tU: YES 0 NO tr 'i APPLIANCES•. FLOORS-, !1°,M 1 2 3 1 5 6 7 ' 84 10 11 12 13 14 I BOILER BOOSTER CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER DRYER l FIREPLACE FRYOLATOR - - ' 1 FURNACE GENERATOR GRILLE INFRARED HEATER , LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT R '_1 4'u 1 r { T HEATER- UNID ROOM HEATER ,-t..'o'' :r WATER HEATER Pc_ OTHER _ F'.,, 1Ii.V� uC_. ,. ,?.J1 y INSURANCE COVERAGE • I have a cumsnt IiabWNty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW L1ABLITY INSURANCE POLICY 0 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 neaal ,an at my signature on this permit application waives this requirement. 771-C--_ CHECK ONE ONLY: OWNER-ET AGENT ❑ SI RE 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 -best of my knowledge '- and that all plumbing work and installations performed under the permit issued fa this application we be in compliance all erbn due Massachusetts State Plumbing Coda and Chapter 142 of the General Lava. r PLUMBER-GASFITTER NAME A e ow P 171-0/44 LICENSE# i SIVA SIGNATURE MP pc MGF 0 ' JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME ADDRESS 7?/ Z-0 CITY bAg ✓c -� STATE//1/M. ZIP 0d 690/ TEL t�g`8TG- '. FAX CELL 7' `/0 'Cogfr EMAIL .. ,S-:/7 c/1)-- . c► f