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HomeMy WebLinkAboutBLDG-19-001237 -r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY LARMOUTH MA DATE August 29,2011 PERMIT# BLDG-19-001237 JOBSITE ADDRESS 93 STRATFORD LN OWNER'S NAME DAVENPORT G OWNER ADDRESS 20 NORTH MAIN STREET SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESO NO2 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 1 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 1 - OTHER 1 OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current Jiabilitv insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES © NOD 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 an 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 Jeffery Ricardo LICENSE# 13256 SIGNATURE MPO MGFO JPO JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP 0 I LLC it COMPANY NAME: Jeffery A Ricardo ADDRESS 9 S MAIN ST, CITY CARVER STATE MA ZIP 023301500 TEL FAX CELL EMAIL S31ON M31A3a NVId #iI11213d $: 3J ❑ ❑lIWi13d 3E11 SV S3A83S NOIlVOIIddV SIHl ON sail SLlON NOI103dSNI IVNId I.INO 3Sl 210103dSNI NOd 30Vd SIHl S31ON NOI103dSNI SVO HOfOa ," MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK eiCITYYa-rn'och pore- IJA DATE F027'/ PERMIT# 3110079110/,2� JOBSITE ADDRESS 93 "r{""" "Q / li OWNER'S NAME V�e'"PO GOW'1ERADDRESS A /mow 5`' TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT 0 EDUCATIONAL 0 RESIDENTIAL©� CLEARLY NEW:[RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 7 FLOORS-. BSIM 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 RECEIVED ! FRYOLATOR FURNACE / - GENERATOR - GRILLE INFRARED HEATER BUILDIN3DE -" 1 LABORATORY COCKS ar: MAKEUP AIR UNIT —T T OVEN POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT . TEST .. . .. _. . _ /. . ..__.. __ -_ UNIT HEATER INVENTED ROOM HEATER WATER HEATER OTHER —505 J 1 INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL C11.142 YES D-I0 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY 0 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. • CHECK ONE ONLY: OWNER 0 AGENT 0 3 SIGNATURE OF OWNER OR AGENT tic, 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 ...visiqs of the -'- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTER NAME S c3 Ji C�O ��LICENSE#/3,25-0 �/ SIGNATURE MP�GF 0 {JPS❑ JGF�❑� �fLLPGI 0 CORPORATION r3# 3/5 y PARTN- SHIP,0#,/ LLC 0# p COMPANY DAME� 9, 6I a`-Cl e/✓'"l� 1 E- ADDRESS Cr retie "" f C^tct All• Gin ( i�no--ts2Y1 STATE /1/741 ZIP Oa3 iO TEL 223 77 y 9r10 Y" FAX CELL- 31 / 4'i5-1 EMAIL rl(thr pk✓-i41:21`.11-Catice:20.4✓_A-e) L$ CiD BOUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NATES Yes No THIS APPLICATION SERVES AS THE PERFv1IT 0 ❑ 4 /34 i0� 1 - FEE: $ PERMIT,/ PLAN REVIEW NOTES geatt api ; ag- 71/4A e(9- /16/7