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HomeMy WebLinkAboutBLDG-23-005802 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 19,2023 PERMIT# BLDG-23-005802 JOBSITE ADDRESS 920 GREAT ISLAND RD OWNER'S NAME GREAT ISLAND 920 LLC G OWNER ADDRESS P 0 BOX 1648 BELLEVUE WA 98009 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: El 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 1 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 ❑ OTHER OF INDEMNITY CI 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 David Roderick LICENSE# 967 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI © CORPORATION❑# PARTNERSHIP ❑# LLC El# COMPANY NAME: DAVID W RODERICK ADDRESS. 83 CLEARWATER DR, CITY HARWICH STATE MA ZIP 026452901 TEL FAX CELL EMAIL russ2cc a(�,gmail.com AirMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i fig �_. h� = ;! a'C Mo tea MA DATE 4-. t T 2`3 '_ '• 9 ZF3 PERMIT# j�U 2 R 19I JE A D- SS, 9 0_.�5 �^! _ , , OWNER'S NAME �._n _ 1 gUr _ 13Y vEpOWNER D•ESS i _ � �� TEL!0 7 Rao_ ti / FAX —__ PST `�- 'ANC TYPE COMMERCIAL EDUCATIONAL CLEARLY _ RESIDENTIAL. NEW; RENOVATION:i.,,r3 REPLACEMENT.1111 APPLIANCES I, FLOORS-, PLANS SUBMITTED: YES I � N0 BOILER BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE -_ surninstamonswamminntnitauraillielitalliMi DIRECT VENT HEATER U. Mr IlinFilliall MM.11.1/1111111111111111111111.101111.11111 DRYER FRYOLATOR - cumiamimmom imisonwsnmerilitilintilliMMINIMINIMMININI GENERATOR r - - INFRARED HEATER LABORATORY COCKS ` =:. �� �_ OVEN 1 POOL HEATER POOL/SPACE HEATER ROOF TOP UNIT ° ' MI MI Iffir.f_TESTN ' UNVENTED ROOM HEATER WATER HEATER ____ siiinglillimprillitimillting,16111110,11.11610111, wilitnirlill, 61.111100,1111111.01.11160110, 4.11.1, OTHER _M - INSURACE ERAGE I have a current liability insurance policy or its substantial equivalent whi hVmeets the requirements I IF YOU CHECKED YES, q of MGL.Ch.142 YES NO PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY F- OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of th Massachusetts General Laws,and that my signature on this permit application waves this requirement. e SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Iand that hereby certify that a work and ll of the details and information I have submitted or entered regarding this application are true and accurate to the best� AGENT m_ Massachusetts State Plumbing(Code and Cions apte performed42 of the General L issued for this application will be I pliance with all erti t of my knowledge pro sion of the PLUMBER-GASFITTER NAME:David W.Roderick Jr. LICENSE#1967 MP t MGF��, A JP� ; JGF 1 z LP�•I� ,� SIGNATURE - CORPORATION' #i -PARTNERSHIP # COMPANY NAME Ca a Oil&Pro ane 1 LLC i #I CITY Provincetown _ ADDRESS PO Box 993 _...___ _ ._-__ _ STATE! MA ZIP 02657 FAX 1508-432-0617 44 CELL 8-246-2051 EMAILservice ca codoil.com � TEL 508-087-0205 �