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HomeMy WebLinkAboutBLDG-22-006591 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE May 16,2022 PERMIT# BLDG-22-006591 ; JOBSITE ADDRESS 65 CIRCUIT RD OWNER'S NAME DIPIAZZA DAVID G OWNER ADDRESS DIPAllA DEBRA 11 BERGEN AVE HILLSDALE NJ 07642 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 111 PRINT CLEARLY NEW: 0 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 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 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 Albert Perry LICENSE# 26791 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ALBERT J PERRY ADDRESS. 10 HERON CIR, CITY MASHPEE STATE MA ZIP 026493418 TEL FAX CELL EMAIL aipplumbingandheatingAvahoo.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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK liff ^ / '-:tom.6 CITY ��T'!" °(frN MADATE -51 1 g 2-2-- PERMITfr 2Z- (.9 S`)f JOBSITE ADDRESS 16 C t2.c.c,t i .24 9 OWNER'S NAME 0 A ) Oi `O f P(4 2-zA OWNER ADDRESS 6 G! TEL 774 35S 403 1AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL$ PRINT CLEARLY NEW:❑ RENOVATION: S S �E ❑� REPLACEtJIENT:� PLAN .,UB�fITTED: 1�S®- Id0 1 APPLIANCES FLOORS-* SSM 1 2 3 4 5 6 7 S 9 10 11 12 13 1 1 BOILER BOOSTER CONVERSION BURNER ' COOK STOVE DIRECT VENT HEATER DRYER _ I FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE _y _ INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT — , OVEN i POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST . . UNIT HEATER r UNVENTED ROOM HEATER J I WATER HEATER OTHER I _ I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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 0 SIGNATURE OF OWNER OR AGENT _b 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 Pertin it prov' 'on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME AK- P err---te'1' LICENSE 4 2 7 q f SI URE MP 0 MGF❑ JP JGF❑ LPGI❑ CORPORATION❑#i PARTNERSHIP❑# LLC❑# COMPANY NAME M. Pfr)C -N PO rvG-f-ff(134-i'� C ADDRESS Le) At mac (-Cr CITY ()-' STATE /`I4 . ZIP d 2-4 f 9 TEL Sag- $i 'cis 17 FAX CELL c Z 6 I"9I,`I EMAIL j,4o/0,,b 447 c-t+d 4cddn ye,tioo Co"-2 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY __FINAL INSPECTION{NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • • • • • • �1