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HomeMy WebLinkAboutBLDG-22-004851 t = MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' 'c' CITY YARMOUTH MA DATE March 03,2022 PERMIT# BLDG-22-004851 ta - JOBSITE ADDRESS 25 CAMP ST OWNER'S NAME Ahmed Shahin G OWNER ADDRESS 25 CAMP ST WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 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 ❑ 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 Peter Rive LICENSE# 13447 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: PETER E RIVA ADDRESS. 9 BAYVIEW ST, CITY MARSHFIELD STATE MA ZIP 020502906 TEL FAX CELL EMAIL peterrivaacomcast.net 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 rti ;6 CITY ��� � 'Ln i MA DATE PERMIT JOBSITE ADDRESS 2_G /"1L"' S ( OWNERS NAME /''trv�9 e J J�11 I GWNERADDRESS ,_�2—IMr eL�c'2c TEL5Zr__ `'7 '. FAX /4/...._ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALfl PRINT CLEARLY NEW:❑ RENOVATION:.-e— REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NG-g`1 I APPLIANCES 1. FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 14 I BOILER _- _�■ { BOOSTER CONVERSION BURNER, ■ I COOK STOVE DIRECT VENT HEATER i i DRYER I FIREPLACE FRYOLATOR !still ________ _ IIPAI.LABORATORY COCKS . I J 1 ENT' 1 POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT _ UNIT HEATER INVENTED ROOM HEATER 1 0 ER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY B OTHER TYPE INDEMNITY ❑ BOND ❑ 1 • 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 wives this requirement. 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 7-• I hereby certify that all of the details and information I have submitted or entered regarding this application are t ,d.accurate to the best of my knowledge and that all plumbing work and instal tions performed under the permit issued for this application will be in co li. .with all P ent provision of the `` Massachusetts State Plumbing C agrd Chapt 42 of the General Laws. LU PLUMBER-GASFITTER NAM • ,__/ t LICENSE# 1 39C.( SIGNATURE MP ❑ MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION 1111 PP.RTNr .SHIP❑# LL #�C, Z W COMPANY NAME 1' & c i ADDRESS Li ("Le �,� 5/ CITY f✓`- N_ 7� l� STATE /,'�t z ZIP TEL /1 / 6 - 3r FAX/ *��1 bZG' G) CELL �� v, �s ( � �� 7Y� EMAIL T/f/•i L71 C ,d-tC. _ -> /4-y ems, o ` -- • 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 •