Loading...
HomeMy WebLinkAboutBLDG-22-005373 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK cy� CITY YARMOUTH MA DATE March 25,2022 PERMIT# BLDG-22-005373 JOBSITE ADDRESS 26 CAMP ST OWNER'S NAME WILLIS DAVID E G OWNER ADDRESS WILLIS LUCILLE F 24 ATWOOD LN SHREWSBURY MA 01545 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS BSM 1 T 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE 1 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 ❑ 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 Zachary Lucas LICENSE# 16865 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MID CAPE MECHANICAL ADDRESS. 300 Queeen Anne Rd., CITY Harwich STATE MA . ZIP 02645 TEL FAX CELL EMAIL midcapemechanicalla7.gmail.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 " _M V BIDS ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,mr 4 An c wr.DA. MA DATE 0 2` 2— PERMIT# ' VD 7 JOBSII1 ADDRESS 2 G C°-K P S} OWNERS NAME ®a,11 y4 (-0 1 r3 BUI I DEPARTMENT By -�,.-. n - •-RESS 26, Ca 1-‘0 S+ TEL <Sea" ?4(/10V.x TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ - • CLEARLY NEW:V RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 NO IQ- APPLIANCES 1 FLOORS-* BSM 1 2 3 4 5 6 7 a 9 10 1.1 12 13 1r BOILER BOOSTER CONVERSION BURNER COOK STOVE • DIRECT VENT HEATER - L. DRYER FIREPLACE I FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER • 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 equivalent which meets the requirements of MGL Ch.142 YES 'NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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 ❑ 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 `k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe 'nent provision of the yl Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7ebj1/1"/ PLUMBER-GASFITTER NAME La caS�� LICENSE tt����S/ SIGNATURE MP 2'. MGF❑ JP ❑ JGF❑ LPGI D CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME ( '�.l C QC Me I-i a.1 r`La ADDRESS Pb 12°X- Al 33 b CITY (A G1.1f2A4"Gt avol STATE s -4 ZIP 0Z G G TEL 5 o8 24(C 7277 FAX CELL EMAIL MEd C412eAlQ(k(f't(GaIela jtAlQ6(, (-0\ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT if PLAN REVIEW NOTES • r 1 •