Loading...
HomeMy WebLinkAboutBLDG-22-003773 c :.,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Iti • CITY YARMOUTH MA DATE January 06,2022 PERMIT# BLDG-22-003773 JOBSITE ADDRESS 11 CAMPION RD OWNERS NAME Pristine Cape Cod Homes G OWNER ADDRESS 11 CAMPION RD YARMOUTH PORT MA 02675-1560 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES ❑ NO❑ 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 0 OTHER OF INDEMNITY 0 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 BRADLEY TOMASETTI LICENSE# 16544 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: TOMASETTI PLUMBING ADDRESS. 103 UNION ST, CITY YARMOUTH PORT STATE MA ZIP 02675 TEL FAX CELL EMAIL 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 c SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK R s * :,t CITY/G, ew ft-r MA DATE f 6 /7 a2 Z PERMIT JAIV u 6 202)OBEITE ADDRESS I I (q hip:e -, /1 ) OWNERS NAME Pr/ 5 C , Zed ti B ILO; tPAR CAYINiTIIER ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: I/ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-f BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 1t BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER . i FIREPLACE FRYOLATOR —� FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN - L-_� POOL HEATER • • ROOM SPACE HEATER ROOF TOP UNIT TEST _. • 1. . .' —� . ..-.... -- -• --- UNIT HEATER UNVENTED ROOM HEATER T� WATER HEATER L---1 OTHER • INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES-Et<❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IE 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 D 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 will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 5.-e LICENSE# fbs'im SIGNATURE MP • MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME /O✓hccc. "/-' /-)Ci. ADDRESS l O-5 14R r`a, Sr STATE /"I s ZIP Z. /9 7 TEL COg- l -14 Q6 1 FAX CELL EMAIL / �'-c+g S r° f/kb„r (2-..;) "^411. cOn. ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY _FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT li PLAN REVIEW NOTES • • • •