The URL can be used to link to this page

Home My WebLink AboutBLDG-23-001365 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE September 14,202 PERMIT# ,� � CITY YARMOUTH BLDG-23-001365 JOBSITE ADDRESS 140 MAYFLOWER TERR OWNER'S NAME IBERG PAUL C G OWNER ADDRESS BERG LOIS J 40 MAYFLOWER TERR SOUTH YARMOUTH MA 02664 TEL I 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 FRYOLATOR • FURNACE 1 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 1 OTHER OTHER DESCRIPTION: —0 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 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. 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 'Phu Huynh I LICENSE# 131519 MP❑ MGF ❑ JP III JGF 0 LPG' ❑ CORPORATION 0#I I PARTNERSHIP ❑# SIGNATURE COMPANY NAME: IPHU HUYNH I ADDRESS. 134 SCHLAGER AVE, CITY IQUINCY I STATE (MA I ZIP 1021697447 I TEL I FAX I I CELL I I EMAIL Ikntran8811(a,gmail.com - CF6USETTS UNIFORM APPLICATIONO o g : . ( - FOR A PERMIT TO PERFORM GAS FITTING WORK _ Y 0EP ' o MA DATE iz_ PERMIT# 23— ! b TE 'D RESS OWNER'S NAME r 2 r• au '�'' G D:�'�L�MDr1�,ESS�/ g -/ � �/� el/" / BU 1111,... — TEL /_ 75g.? /P' 7 PRINT OCCUPANCY TYPE -`—FAX COMMERCIAL❑ EDUCATIONALRESIDENTIAL CLEARLY ❑ �� NEW:❑ RENOVATION: REPLACEMENT: ❑ APPLIANCES PLANS SUBMITTED: YES 0 NO Q BOILER FLOORS-+ ipitallpirranilliall BOOSTER •13 tCONVERSION BURNER COOK STOVE Milv - DIP,ECT VENT HEATER I4— —I_ ____ ® .. - INFRARED HEATER v v _ LABORATORY COCKS v — MAKEUP AIR UNITEll _ POOL HEATER MINIM all IIIIII _�IIIIIMIIIIIIIIIIIII ROOM/SPAC:E HEATER — ROOF TOP UNITIIIIII MIN MIN NM= UNIT HEATER _® ® ® 1 UNVENTED ROOM HEATER WATER HEATER ,� all all IIIII _ OTHER -111111 _ _ w.....m...m......_IIIIIIIIinmmmmmuIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII GE Ihave a Curren INSU�miminiummiim_________,...........111111airalrev t liaki1i insurance policy or its substantial equivalent whichGVm�S the requirements of MGL.Ch.142 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECI�CIhlG THE APPROPRIATE BOX B YES In/NO ❑ LIABILITY INSURANCE POLICY BELOW OWNER'S OTHER TYPE INDEMNITY ❑ BOND INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by ❑ Massachusetts General Laws,and that my signature on this permitapplication waives this requirement. t q Chapter 142 of the ,e q EmEetk. .-\ SIGNATURE OF OWNER OR AGENT CHECKONE ONLY: OWNER 0 "I I hereby certify that all of the details and information I have submitted or entered regardingthis AGENT 0 and that all tify that n work performed 9 and iCtallati dpt14of the the permit issued for this application will be in compliance with all pertinent Li t Massachusetts t l State work aCode application are true and accurate to the best provisionm knowledge - Plumbing and Chapter of the fthe PLUMBER-GASFITTER NAME General Laws. of the MP❑ MGF❑ UP ^/ LICENSE#3/S/9. SIGNATURE Ild JGF❑ LPGI ❑ CORPORATION COMPANY NAME ❑# PARTNERSHIP 0�� CITY ADDPFSS .31� (,,. fQ �' A-Y FAX STATE •ez ZIP_ 402/� CELL4iy . TEL - /f/ �' _ EMAIL ./