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HomeMy WebLinkAboutBLDG-23-002533 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK WCITY YARMOUTH MA DATE November 08,202; PERMIT# BLDG-23-002533 JOBSITE ADDRESS 2 DOGWOOD DR OWNERS NAME STELLA MICHAEL R OWNER ADDRESS 2 DOGWOOD DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT • OVEN POOL HEATER ROOM/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 0 OTHER OF INDEMNITY 0 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 Dean Farnham LICENSE# 13203 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: IDEAN P FARNHAM I ADDRESS. 18 WILLOW WAY, CITY (SOUTH DENNIS STATE MA ZIP 1026603060 TEL I FAX I CELL I EMAIL Ideanfamham56(cilgmail.com • 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 - .vf. , _ . ,.t . c.. Mr, DATEll- PERMIT V 08 2022ITE AD RE•SS ' C-X G5 C,jc�-J CI( `,'(--)._ OWNERS NAME / 7 c,--7- OWNER.ND RESS TEL 7,W CS7 5 &EF•AY BUILDING DEPARTMENT BWPRT OR 'r TYPE COMMERCIAL❑ EDUCAT 'NAL ❑ RESIDENTIAL ga'"-/ CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ APPLIANCES T FLOORS-I SSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14 BOILER BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER L__ DRYER FIREPLACE FRYOLATOR ` FURNACE GENERATOR • ` GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER • ROOM I SPACE HEATER • ROOF TOP UNIT TEST 6.ce, �1j /7`,'�. .. . . . - . . . . ._ i UNIT HEATER INVENTED ROOM HEATER r I WATER HEATER OTHER INSURANCE COVERAGE - I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF OWE .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 ONLY: OWNER ❑ AGENT 0 " SIGNATURE OF OWNER OR AGENT '„I• I hereby certify that all of the details and information I have submitted or entered regarding this application are tr.- and accur,-te est of my knowledge ` • and that all plumbing work and installations performed under the permit issued for this application will be in co pliance with nent provision of the �'• Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .‘11 - PLUMBER-r'ASFITTER NAME LICENSE# 13 03 ! PIAIURE MP ! MGF 0 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# •LLC 0# COMPANY NAME 1"-- .,-�t h�- ADDRESS / r r/.�-./ (�� CITY S. �Pil.-l.. STATE l? 4- ZIP C---i l/C TEL -SGiS� / ' ? --r?6 FAX CELL EMAILC � ,s rG...,, .-'~s-c 6-- "% - C 6-, • 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