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HomeMy WebLinkAboutBLDG-22-002093 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH MA DATE (October 12,2021 PERMIT# BLDG-22-002093 JOBSITE ADDRESS 20 AZALEA LN OWNER'S NAME Larissa Da Silva G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 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 1 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❑ 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 (Andrew Leighton LICENSE# 116130 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPGI 0 CORPORATION❑#I PARTNERSHIP ❑# LLC ❑# COMPANY NAME: IANDREW R LEIGHTON ADDRESS. 120 Brewster Rd, CITY IW Yarmouth STATE MA ZIP 1026735706 TEL FAX 1 I CELL I EMAIL Ihalloilcompany()a,gmail.com .1- k MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK riff Z `:=?:ice,. CITY 50041 \I O f fi1O14\ MA DATE IC)/ 01. / OLI PERMIT# JOBSITE ADDRESS 2\0 14 Zal>`,a, Land, OWNER'S NAME LaA ASS G�.. \1as DaS}I V&.. GOWNER ADDRESS a0 p-Znlin hell\{, c5•\la 0v' TEL "a-la- a4CIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL.. PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES Z 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 _ , GRILLE - INFRARED HEATER - LABORATORY COCKS MAKEUP AIR UNIT _ OVEN _ POOL HEATER _ ROOM I SPACE HEATER R E C E J V ROOF TOP UNIT TEST - ,>� • OCT 08 20 UNIT HEATER _ UNVENTED ROOM HEATER SuILDING utLgART ENT WATER HEATER — By. _ OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO K I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSU-,. «i' - I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts G' . that my signature on this permit application waives this requirement. II opCHECK ONE ONLY: OWNER AGENT ID SI _. e���� ' OR AGENT hereby certify that e'r the details and information I have submitted or entered regarding this application are t - -n• -cc to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c pli. .'wi - ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / , PLUMBER-GASFITTER NAME LICENSE# tip t 3 0 SIGNATURE e4 MGF❑ JP❑ JGF❑ LPGI ❑ 91RPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME C Ml7✓CLr.f 1.--- 1d/ ADDRESS o f D - CITY u(-r---- yA4-tAioard STATE M C\ ZIP o TEL TEL 5$ '1-7 C:, '2L S FAX CELL EMAIL C75 Z-rt.-` Lice A4 45,C