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HomeMy WebLinkAboutBLDG-23-000678 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c CITY YARMOUTH MA DATE August 09,2022 PERMIT# BLDG-23-000678 JOBSITE ADDRESS 4 NICKERSON FARM WAY OWNER'S NAME TINELLI TERESA G OWNER ADDRESS 4 NICKERSON FARM WAY SOUTH YARMOUTH MA 02664 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 1 BOOSTER CONVERSION BURNER COOK STOVE 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER OF 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. 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 `Francois Paravisini I LICENSE# 115211 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: IFRANCOIS PARAVISINI ADDRESS. (PO Box 2585, CITY (Orleans STATE MA ZIP 1026536585 TEL I FAX I CELL I I EMAIL Ibaysideto7.thecapecodplumbers.com MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK sz_m CITY Yi\R M o Lk-10 MA DATE 8/4/7-2- PERMIT# 2-1 ` °(6-7 F JOBSITE ADDRESS -LI Nit C (Z 'FARM WA' OWNER'S NAME R( k J R- G OWNER ADDRESS Tali -$.310-634 01 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL an PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:, PLANS SUBMITTED: YES❑ NO❑ APPLIANCES . FLOORS-► 8SM 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 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 INSURANCE COVERAGE I have a current liabilIty insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ►:4 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW !ABILITY INSURANCE POLICY IS OTHER TYPE INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance cue 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 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this appl' �e 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'ln born with all Pertinent - Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#15211 1 SIGNATURE , MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION®#205872589 PARTNERSHIP 0# LLC❑# COMPANY NAME Bayside Plumbing &Heating ADDRESS P.O. Box 2585 CITY Orleans STATE MA ZIP 02653 TEL 508-255-4555 FAX 774-316-4249 CELL 774-216-9484 EMAIL Bayside@TheCapeCodPiumbers.com 50 4-so 41 00 212J.