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HomeMy WebLinkAboutBLDG-23-005704 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l/ CITY YARMOUTH MA DATE April 13,2023 PERMIT# BLDG 23 005704 JOBSITE ADDRESS 15 POWERS LN OWNERS NAME BRUNO BEVERLY A G OWNER ADDRESS 83 CIDER MILL RD HAWTHORNE NJ 07506-3042 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III 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 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 El 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 Gary Jones LICENSE# 88908890 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: GC JONES PLUMBING&HEATING ADDRESS. 12, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL 5085092725 EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k!'".� CITY: i (/n O VI II MA. DATE q I --62_3 PERMIT# JOBSITE ADDRESS: L5 PC CA e-(5 fJ- iv_ OWNER'S NAME: Ve-il curio GOWNER ADDRESS: I S Pd -r5 l 11 • TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOOR—I Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ell BOOSTER CONVERSION BURNER COOK STOVE d DIRECT VENT HEATER I DRYER FIREPLACE ` FRYOLATOR FURNACE 1 GENERATOR h GRILLE tr) INFRARED HEATER w LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM!SPACE HEATER l ROOF TOP UNIT t ,TEST �► UNIT HEATER I u UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [Q OTHER TYPE INDEMNITY ❑ BOND Cl OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts I ,and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGN F 0 OR AGENT 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 wit be In compliance with all Pertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. PLUMBERIGASFITTER NAME -e f\G(1BJ LICENSE# 6 9 d SIGNATURE COMPANY NAMED lit- C JC1 lP_5 494-fri LL C. ADDRESS: )a•1 eciric,✓l 431 r Cry: W 6&1 *G I U( STATE MI ZIP: '3 FAX: TEL: CELL;50K a7,9S EMAIL ✓c.J rlQ5®CYI -4 yGr . MASTER JOURNEYMAN❑ LP INSTALLER[❑ CORPORATION El# PARTNERSHIP❑# u.0 C h21y/(. A1»eSS