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Home My WebLink About8 Pierce Contract - signed.pdf MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Es IIICITY YARMOUTH MA DATE August 09,2021 PERMIT# BLDG-22-000752 JOBSITE ADDRESS 8 PIERCE ST OWNER'S NAME Elizabeth Ciampa G OWNER ADDRESS 8 PIERCE ST WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 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 1 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 1 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 El 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 Jeremy Gates LICENSE# 26002 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Jeremy A Gates ADDRESS. 3 BRANDT ISLAND RD, CITY MATTAPOISETT STATE MA ZIP 027391706 TEL FAX CELL EMAIL S310N M3IA3a NVId #1IW213d $:33d ❑ ❑ 1111213d 3Hl SY SAS NOIlv3IlddV SIHl oN so), SALON NO1103dSNI 1VNId AINO 3Sfl 210103dSNI a0d 30Vd SIHl S3LON N01103dSNI SVO HOflOa RECEIVr.v AUG 0 9 2021 -1-- )ART ► A;.HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '--- ; t," CITY: I /c4JrY1 c'-' 11') MA. DATE: (L I - Z ( PERMIT# 7-Z--7 S Z---- JOBSITE ADDRESS: 1 e r- - `7 ( OWNER'S NAME: 1 )DA-be Th Ck.A_eini --k. G OWNER ADDRESS: '5 '1 1 J:,—,,I7 \ sN c\-r) I c' TEL: 7) 1-6 C'1 ?GVVFAX: TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:Er REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOOR Bsmt _ 1 2 3 4 5 6 , 7 8 9 10 ` 11 12 13 14 BOILER BOOSTER I CONVERSION BURNER I + COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR _ _ FURNACE GENERATOR GRILLE VI INFRARED HEATER I 14 LABORATORY COCK MAKEUP AIR UNIT ` OVEN POOL HEATER T. ROOM/SPACE HEATER •J ROOF TOP UNIT Z TEST _ Z UNIT HEATER I ti UNVENTED ROOM HEATER WATER HEATER 1 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 have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE 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. CHECK ONE ONLY: OWNER 0 AGENT El SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best y Knowledge and that all plumbing work and installations performed under the permit issued for this application will be In pUan a ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r- PLUMBER/GASFITTER NAME: �t�"Ci ly r;� d 5 LICENSE#16 0 4 L - / NA ` v COMPANY NAME: 1 1 c t Q 1� -J ) (: " �1 X � rC ADDRESS: � Q V•rN, t 1 .1<0c c� ..)e C)s 1 1 CITY: I,1 1�l c-oil , S STATE: V� ZIP: (7_,‘ 2-( ti FAX: n TEL: CELL: \1)-7 `1 V l ?c. _EMAIL: MASTER❑ JOURNEYMAN 3 LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# c h24 ic., 1)&0,2e-5S : __)Q@hv e , . Ic ) ..c :..�,i.t p Jr <,