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HomeMy WebLinkAboutBLDG-21-007498 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' pi CITY YARMOUTH MA DATE June 24,2021 PERMIT# BLDG 21 007498 5' r JOBSITE ADDRESS 17 PEREGRINE LN OWNER'S NAME BURKE CHRISTOPHER J G OWNER ADDRESS BURKE JUDITH M 14 KIMBALL AVE WAKEFIELD MA 01880 TEL l TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 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 1 FRYOLATOR , FURNACE GENERATOR GRILLE • INFRARED HEATER • LABORATORY COCKS , MAKEUP AIR UNIT , OVEN • POOL HEATER • ROOM I 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 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP 026735706 TEL FAX CELL EMAIL halloilcompany@gmail.com . ,_ E `S UNIFORMAPPLICATION PE RMI! TO PERFORM GAS FITTING WORr =-�_ r CITY So , U0s-lc" el - MADATE ��3 A/ PERMIT6C Ls-co)`ISM " S ITE ADDRESS P'? PQ re0,+t-ru e 1"- .-OWNER'S NAME CAP/sta.-ph/4 lP AeGOWNERADDRESS TYPE OR 7 EL 0 L P-Pt?-gYg6 F,q PRINT OCCUPANCY-ME COMMERCIAL EDUCATIONAL RESIDENTIAL. / CLEARLY NEW: tREN0VATION: REPLACEMENT: APPLIANCES� �LOORs-. - PLANS SUBMITTED: YES NOBOILER t3 1 213 4 5 $ T a to tt 72 ( t3 BOOSTER _ .. . CONVERSION BURNER .-.- i COOK STOVE - - t • DIRECT VENT HEATER i FIREPLACE _DRYER FRYOLATOR I FURNACE i :;_t, f GENERATOR GRILLE _ i INFRARED BEATER LABORATORY COCKS MAKEUP AIR UNIT • - „ - OVEN - POOLHEATER " '' 1. • • . • _ ROOM/SPACE HEATER _ __ ROOF TOP UNIT -. TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER - OTHER /' - — 1 - - . . , ! I', i i ___:. I have a current6asbiTliv insurance policy COVf�AAE Policy or Its substentlal equivalentivhich meets-the requirements of MGL Ch.l42 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OP COYERAGESYCHE KING DE APPROPRIATE KIK I3ELOW LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY OWNERS INSURANCE I� ,t that the� BOND - Massach General Laws,and thatcensesss h ve the II waives h s rcoverageequIrm of the my on this Imothis���. SIGNATURE OF OWNER OR AGENTCHECK ONE 0 ; OWNER AGENT I ICY mall of the dotage and information I have submitted or entered this and that an saw Instaaatione C � me Lashed tar - areand Massachuses Sty Plumbing Chapter 142&the Ganesbe Laws. of the PLUMBER-GASFITIER NAME ANDREW L�HTON - RAP e LICENSER 16130-M SIGNATURE MGF JP JGF LPG! CORPORATION r COMPANY NAME HALL OIL COMPANY INC. ADDRESS 3, PARTLULH2SditP LLC CITY SOUTH DENNIS • 435 RT 734 FAX 508 3943068 STATE MAZIP_� EMAIL i�oEr y .tntri 398-3831