Loading...
HomeMy WebLinkAboutBLDG-23-006040 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �"' `1, CITY YARMOUTH BLDG-23-006040 ' e MA DATE May 02,2023 PERMIT# JOBSITE ADDRESS 50 LAKE RD WEST OWNERS NAME THERIEN LAWRENCE W G OWNER ADDRESS THERIEN EILEEN 50 LAKE RD W WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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 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 LEON CLARK,JR LICENSE# 11734 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG( 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ITC TYNDALL&CLARK PLUMBING&HEAT ADDRESS. 118 ATLATNIC AVE, CITY (SOUTH DENNIS STATE MA ZIP 102660 TEL 15083858868 FAX I CELL I EMAIL Ikarenna,tcplumbinq.net MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK g CITY YARMOUTH MA. DATE 4/26/2023 PERMIT#d3LDC. za- `t 6 JOBSITE ADDRESS 50 LAKE ROAD WEST OWNER'S NAME THERIEN Cj OWNER ADDRESS: WEST YARMOUTH TEL: 508-246-7864 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑■ PLANS SUBMITTED: YES❑ NO I FIXUTRES 7. FLOOR-' Bsmt 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 LABORATORY COCKS MAKEUP AIR UNIT R E �i E ` OVEN POOL HEATER AY 0], 2023 ROOM/SPACE HEATER M ROOF TOP UNIT TEST DUILbIt44 Of t‘ri i OJT UNIT HEATER B UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES It NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY ID 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 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 appli lion will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: LEON E CLARK,JR. LICENSE# 11734-M SIGNATURE COMPANY NAME: TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE CITY: SOUTH DENNIS STATE: MA ZIP: 02660 FAX: 508-385-9177 TEL: 508-385-8868 CELL: 508-367-1452 EMAIL karen@dttcplumbing.net MASTER ID JOURNEYMAN 0 LP INSTALLER 0 CORPORATION LI# PARTNERSHIP 0# LLC❑#