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HomeMy WebLinkAboutBLDG-21-006738 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' E: CITY YARMOUTH MA DATE May 20,2021 PERMIT# BLDG 21 006738 JOBSITE ADDRESS 49 DOHERTY LN OWNERS NAME POWERS MARK B G OWNER ADDRESS PO BOX 641 WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES El 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 DIRECT VENT HEATER DRYER FIREPLACE 2 FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER 1 OTHER DESCRIPTION:1 outside fire pit INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO El 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 Angelo Pistoftzian LICENSE# 3183 SIGNATURE MP El MGF © JP El JGF El LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ThermOil Inc. ADDRESS. P.O.BOx 42, CITY Watertown STATE MA ZIP 02471 TEL 6179260779 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