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HomeMy WebLinkAboutBLDG-23-002570 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '"' CITY YARMOUTH MA DATE November 09,202: PERMIT# BLDG-23-002570 w JOBSITE ADDRESS 5 DUNDEE DR OWNER'S NAME Lorianne Quinn G OWNER ADDRESS 5 DUNDEE LN YARMOUTH PORT MA 02675-1518 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 . FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 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 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. 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 (Anson Celin LICENSE# 132655 SIGNATURE MP 0 MGF 0 JP© JGF 0 LPGI 0 CORPORATION 0#I I PARTNERSHIP 0#1 ILLC 0# COMPANY NAME: IANSON CELIN I ADDRESS. 126 Capt.Blount Rd, CITY (South Yarmouth I STATE MA ZIP 102664 I TEL I I FAX 1 1 CELL I I EMAIL (ansoncelin(),Vahoo.com I r--- l 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 ''7..--__ i`-#'- CITY (,t Gc O AI '0(l MA DATE i ' f' ZZ PERMIT# Z3-2 S "7o JOBSTE ADDRESS S iDu'De .. Dr OWNER'S NAME L on C.nOC 'Q.ui "In OWNER ADDRESS Sr T)i;,.4r1 j�ce J r TEL S'a i - —-C/4AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:d RENOVATION:0 REPLACEMENT:❑ PLANS SUBMI I I ED: YES❑ NO[ ' APPLIANCES 1- 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 i POOL HEATER / T { ROOM I SPACE HEATER _ ROOF TOP UNIT TEST ..__.. __ -. _._ _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE �,/ I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL.Ch.142 YES l< 10 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ild" 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 tb 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 c piiance with all Pertinent provision of the .' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Li I PLUMBER GASFITTER NAME a,r\ r\ CC,I''\ LICENSE# 32GSS` SIGNATURE MP 0 MGF❑ JP"JGF 0 LPG'❑ CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME CC'l." ll" l c4476r h. ADDRESS 16 Ca;.-1 6/0(.n.„1.- AV- CITY SC>tuchri tif C4414ickArtA STATE/k) A ZIP �C1 G TEL TEL J G�2_44 rig-� Z 7G ! FAX CELL EMAIL sL e Iit&tall- - L Grh ROUGH GAG INSPECTION NOTES THM'AGE FOR INSPECTOR USE ONLY I+II>IAi INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT fI PLAN REVIEW NOTES •