Loading...
HomeMy WebLinkAboutBLDG-23-005369 4 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1' CITY LYARMOUTH MA DATE March 30,2023 PERMIT# BLDG 23 005369 ---__Il � JOBSITE ADDRESS 168 CAPT NICKERSON RD OWNER'S NAME MICHAEL CURLEY G OWNER ADDRESS MEGHAN AND JAMES CASEY 24 HAMPTON CT WALPOLE 02032-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 111 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 1 GENERATOR GRILLE 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 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 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 Richard Nagle LICENSE# 10756 SIGNATURE MP© MGF El JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RICHARD F NAGLE ADDRESS. 12 Funn Pond Rd, CITY South Dennis STATE MA ZIP 026601906 TEL FAX CELL 5083140406 EMAIL rfnaale1960na.amail.com � r 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 �fi r CITY ( (,t MA DATE -2] 2,0 2.3 PERT? - '73- 1°53(9 JOBSITE ADDRESS It,$ cc,e /1 N c ker n OWNERS NAME Sam C OWNER ADDRESS n1•e TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: t, REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ APPLIANCES 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 j FURNACE �. GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • _ MAKEUP AIR UNIT OVEN POOL HEATER • ROOM ISPACE HEATER ROOF TOP UNIT R F C E I d TEST - - • 521- UNIT HEATER UNVENTED ROOM HEATER WATER HEATER �--- OTHER t3JILDI GDE-- — INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ 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 ❑ 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 `- and that all plumbing work and installations performed under the permit issued for this application v U,LI t compii ce with all Pertinen provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# ion SIG ATURE MP 1 _� MGF❑ JP❑ JGF❑ LPGI El CORPORATION CI PARTNERSHIP❑# LLC❑# COMPANY NAME r 1 F 5- plv^'t b'^S ADDRESS 12- c h(' CI)rld RCP CITY -'q1 I S STATE n1 ZIP 0�4-460 TEL7531-237r FAX CELL of 3/9 G,4' 6 EMAIL )2 f- Akzsie-6go€ mail " coo/ • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTI)N S Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE: $ PERMIT# PLAN REVIEW NOTES