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HomeMy WebLinkAboutBLDG-23-003301 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK BLDG-23-003301 �, ,_ °, CITY YARMOUTH MA DATE December 13,20Y PERMIT# - rI JOBSITE ADDRESS 81 BRAY FARM RD NORTH OWNERS NAME COHEN NEIL S G OWNER ADDRESS FULWIDER-COHEN LESLIE 81 BRAY FARM RD NORTH YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW: m 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 1 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 • 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 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 Warren Burrell LICENSE# 13628 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: WARREN T BURRELL ADDRESS. 105 SANTUIT POND RD, CITY MASHPEE STATE MA ZIP 026492430 TEL FAX CELL EMAIL burrellplumbinq(a)taol.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 fVIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Via. — t VI •, ', ,e .n1 o c) MA DATE 12-1 ' ) ZZ PERMIT# r...._. JGBSITE tDr RESS -6 1 C c<-0,►--q-'` Jf DWNER'S NAME___Oz.s`�� ' 0t 2 M R e,DD .ESS TEL FAX • BL*Pau ' TMEr4C TYPECOMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL � — ar FEINT_ CLEARLY NEW: P RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ I I i APPLIANCES 1 FLOORS-+ BSM 1 2 3 1 5 6 7 8 9 10 11 12 •13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER (— I DRYER, I i FIREPLACE FRY OLATOR FURNACE li GENERATOR GRILLE i INFRARED HEATER LABORATORY COCKS • 1 MAKEUP AIR UNIT I OVEN POOL HEATER 1 ROOM I SPACE HEATER ROOF TOP UNIT TEST . .._-_.. -- . --- UNIT HEATER UNVENTED ROOM HEATER • WATER HEATER OTHER L_2 0 INSURANCE COVERAGE 1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �O ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er— OTHER TYPE INDEMNITY ❑ BOND ❑ I • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the I• I Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ •� SIGNATURE OF OWNER OR AGENT 1. 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 c pliance with a eminent provision of the `' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `� PLUMBER-G AS NAME LICENSE# t340 Z� SIGNATURE MP MGF❑ JP ID JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑# COMPANY NAME s4 Q -*. ' ADDRESS I 6--- .5-------1- - Cam-- 4 CITY \I"AA- _ STATE 1\-A6-- ZIP v 1---4-"-t'-i TEL P'r-5--F--(f t. � FAX CELL13>'Y $2-`-4-'t"'Clrf EMAIL ROUGH GAS INSPECTION NOTES ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: $ PERMIT f S PLAN REVIEW NOTES • 1