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Home My WebLink AboutBLDG-22-002829 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK aei CITY 'YARMOUTH I MA DATE (November 16,20211 PERMIT# BLDG-22 002829 JOBSITE ADDRESS 119 AUTUMN DR OWNER'S NAME (COLLINS JAMES E G OWNER ADDRESS 'COLLINS JANE M 19 AUTUMN DR SOUTH YARMOUTH MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL El CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 • 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY 0 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 (Sean Oleary I LICENSE# 13957 SIGNATURE MP 0 MGF 0 JP❑ JGF 0 LPG' ❑ CORPORATION 0#I I PARTNERSHIP ❑# LLC 0#I COMPANY NAME: (SEAN F OLEARY ADDRESS. 12 FABYAN RD, CITY 'PLYMOUTH STATE MA ZIP 1023602390 I TEL I FAX I CELL I I EMAIL I _ MA. CACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK \4 i 6 .,cI,Y_ - MA DATE PERMIT# 2-1--1-7-2-5 �' I 1 6 2O� 4IT ACRESS / g jelur`o 'yj,� iv •• OWNERS NAME_-- �- ) i :u, U HApygi �ArDRESS : TEL ^��° AY, 'FiTPE�� -u —� ,. Y TYPE COMMERCIAL EDUCATIONAL �r_)P T ❑ ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: L� PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-1 FLOORS-I' BSM 1 2 3 4 5 6 7 8 9 10 11 12 IT 1— BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE j FRYOLATOR j FURNACE _1 GENERATOR / r—_ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN --� POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT t TEST —__ --- UNIT HEATER UNVENTED ROOM HEATER WATER HEATER -1 OTHER I INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E 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. SIGNATURE OF OWNER OR AGENT CHECK ONE i� OWNER 0 AGENT El ` . I hereby certify that all of the details and information I have submitted or entered regarding this application are true >nd accurate to the r / and that all plumbing work and installations performed under the permit issued for this application will be in co LII Massachusetts State Plumbing Code and Chapter 142 of the General Laws. be my knowledge �� with all P.-� en -,�ision of the PLUMBER-GASFITTER NAME /L/ 0 LICENSE# SI�,� RE MP❑ MGF 0 JP34,p4-77JGF LPGI ❑ CORPORATION❑41 6 v l PARTNERSHIP„, HIP❑# LLC❑# COMPANY NAME - Lyl ADDRESS J41 I /L/ f CITY U 14. ,,"� /' Q FAX STATE 210_ ZIP 7j Cj^� TEL C r/ 'N CELL__Y IL- �"1, i EMAIL V FA C . •/' i4