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HomeMy WebLinkAboutBLDG-23-004228 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .` 6T' CITY YARMOUTH MA DATE January 31,2023 PERMIT# BLDG 23 004228 lI E JOBSITE ADDRESS 45 CAPT LOTHROP RD OWNER'S NAME ZAHN AMY M PAYNE G OWNER ADDRESS ZAHN SCOTT D 45 CAPTAIN LOTHROP RD SOUTH YARMOUTH MA 02664-1740 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ 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 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 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 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 Ralph Giangregorio LICENSE# 9339 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RALPH J GIANGREGORIO ADDRESS. 188 Route 28, CITY Dennis Port STATE MA ZIP 02639 TEL FAX CELL EMAIL officena,3gsplumbing.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 /rlit . rtr IN.0 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -'tIt P. ., I 1 \J �rre J MA DATE I ,- 1 PERMIT# 23 ZZ 5' i 0 0SI1 E AODRESSI ,( �;I L I OWNER'S NAME r "\-17 0-t--c- 1 i S 1 OWNE�t ADDRESS L�"- t ry I TEI OB-4,6-(1 1-i 1 IFAX t,,,,,,,,,,,a„= Bills ?11 HHRTMENT B — 4:1tS I �nr-41 P NflY TYPE COMMERCIAL El EDUCATIONAL Q RESIDENTIAL lid CLEARLY NEW:Q RENOVATION:Q REPLACEMENT:Er PLANS SUBMITTED: YES NoLEr APPLIANCES'I FLOORS-I NM 1 I 2 3 4 8 8 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER ° 1 COOK STOVE IMI DIRECT VENT HEATER tal: DRYER FIREPLACE ofi �_ I' FURNACE it I -0,— _� _... GENERATOR GRILLE INFRARED HEATER i if y. LABORATORY COCKS MAKEUP AIR UNIT , IOVEN . -,_ � • POOL HEATER 1 ROOM/SPACE HEATER ROOF TOP UNIT TEST ,: r.._ ,_.. - ,-- UNIT HEATER e r _ . UNVENTED ROOM HEATER � � s _ __ -� .. _•- _:_ WATER ftEATER OTHER j] I I . . _ ,M KURR NM INSURANCE COVERAGE Er I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES I�GI NO Q I iF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ed OTHER TYPE INDEMNITY Q BOND Q 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 Q AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that ail 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 comp ce with ail P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / _ PLUMBER-GASFITTER NAME ,o t9 A " A) -I F. G-p 1Q,1�*ICENSE#1, 1 SIGN E ice MP 0 MGF Q JP 0 JGF Q LPGI Q CORPORATION N#lai PARTNERSHIP D#E LLC Q# --j COMPANY NAME: _9„(,,, /, d4,-,.,„,ipmandic.V I ADDRESS !SS . CITY ,)5,f/,vi.,S P/) -?. STATE ZIP' Qa‘,3q ITEL cS'd' 3q7 354/6 —1 FAX Liii-3?Y a.g1 CELL }EMAIL P f