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HomeMy WebLinkAboutBLDG-21-001584 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK : ! CITY YARMOUTH BLDG 21 001584 MA DATE September 25,202 PERMIT# II g� JOBSITE ADDRESS 21 CAPT CHASE RD OWNER'S NAME CONNORS FRANCIS X G OWNER ADDRESS CONNORS DONNA M 21 CAPTAIN CHASE RD SOUTH YARMOUTH MA 02664-1732 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 1 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 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 ❑ 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❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RALPH J GIANGREGORIO ADDRESS. 188 Route 28, CITY Dennis Port STATE MA ZIP 02639 TEL FAX CELL EMAIL office@3gsplumbing.net ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El ❑ FEE: $ PERMIT# PLAN REVIEW NOTES -,. MA-9: VA- RCIEL.' . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ;r,t a =.7ns :1,1 .Y` CITY 1..Sayl ' QJidY, I MA DATE I_I______I PERMIT#61...,jG--. J--I 1 JOBSITE ADDRESS -5 1_ 9 1.1✓ _ _I OWNER'S NAME L ,t j _�y __ -- -- - -- GOWNER ADDRESS L ,..5-19/7 f . ...__ . _ Y._._._._ i TE are S'-3bo -g33I FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YESLJ NO® APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER NM . ._ MP Illill _ 1101111111111,111111111 BOOSTER X MIMiLCONVERSION BURNER H . i� .,M COOK STOVE DIRECT VENT HEATER i RAM DRYER ®, 01 I FIREPLACE fRYO TOR1 ; '?> it w I FURNACE l�� GENERATOR IW1la� INFRARED HEATER , . GRILLE , , „ LABORATORY COCKS MAKEUP AIR UNIT 8, NAM . . K ,� MN, , .. OVEN 4 1- - - ;E POOL HEATER ROOM/SPACE HEATER m , ROOF TOP UNIT U ,' TEST l9 UNIT HEATER __ WI r . . i _._... UNVENTED ROOM HEATER l r. ' ) MI a 1OWL - WATER HEATER OTHER(— I, a Mir 1111011111.1111 IN - ‘ I. * 11 INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L 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 ® 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 co 'lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 04-1p13, Gjiw&RE6zik.L6 k J-1,11 LICENSE#1'3,}y SIG TURE MP® MGF 0 JP® JGF 0 LPGI® CORPORATION 21#1,39 9 O c PARTNERSHIP®#[(LLC®#L COMPANY NAME: 3,G-'5 pi,,Ai 1,,,, r-- -j < < ADDRESS 19 A 1 �Sl CITY MEA/A./I 3 Q T _ I STATE m R , ZIP. Oa 434 JTEL L'D 39 "3q 4 6, 1 FAX 1 ?Y-�18.71 CELL EMAIL i r