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HomeMy WebLinkAboutBLDG-23-005986 ' - ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ` CITY YARMOUTH MA DATE April 28,2023 PERMIT# BLDG 23 005986 JOBSITE ADDRESS 25 CAPT SMALL RD OWNER'S NAME GABRICK STEPHEN J JR G OWNER ADDRESS C/O TEEHAN MARK J 6 CAPTAIN EDGAR DR NORTHBOROUGH MA 01532 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 ❑ OTHER OF INDEMNITY CI 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 matthew coleman LICENSE# 34368 SIGNATURE MP❑ MGF ❑ JP© JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: MATT COLEMAN PLUMBING AND HEATIN ADDRESS. 5 college st, CITY west varmouth STATE MA ZIP 026733792 TEL FAX CELL 9788854343 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 ' � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY j()i.� Diu 'r,� MA DATE L'l/a7/a PERMIT# z 3 - 59 8C, JOBSITE ADDRESS aS ca p z c 6011 ✓' d OWNER'S NAMEI 11 U.I 7aj 171 (;(4 OWNER ADDRESS 5 ca/j -1-a 5-Mai/ rd TEL 7 -M13 13 FAy � �y TYPE OR OCCUPANCY TYPE COM ERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ei PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES Ly NO❑ APPLIANCES i• FLOORS-I BSM 1 2 3 4 5 6 7 e 9 10 11 12 1; 14 BOILER BOOSTER _-- CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER —j LABORATORY COCKS • • MAKEUP AIR UNIT OVEN POOL HEATER e ROOM I SPACE HEATER ROOF TOP UNIT iPR 7 TEST ... . .. ...._ .._.._ UNIT HEATER _ (INVENTED ROOM HEATER • -Britt -NiroG ��r}AF�`7wcry WATER HEATER ay - — -_f OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LINO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 eel. 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 rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE 49 (.8 SIGNATUR MP❑ MGF❑ JP Ec JGF❑ LPG(❑ CORPORATION❑# PARTNERSHIP❑* LLC❑# COMPANY NAME Art W)e.iikutii P Tl ADDRESS 7 L{j I'epjt S'I CITY v e 5 4 'lN;In //,, STATE I�1�l,�-t ZIP 0(�6 l �j TEL tp '(g� S-L1?I y FAX CELL"i 7�5"D�yCc O� `i- 4-5 EMAIL Pixel Co e vJ'laj4`J 7� 0-5 90/14.411 4 ROUGH GAS INSPECTION NOTES MILS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • •