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HomeMy WebLinkAboutBLDG-22-005203 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F ., CITY YARMOUTH MA DATE March 17,2022 PERMIT# BLDG-22-005203 rl` 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 El RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 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 UNIT HEATER UNVENTED ROOM HEATER • WATER HEATER , OTHER 1 • 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 El 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 Brian Springsteen LICENSE# 12593 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: BRIAN E SPRINGSTEEN ADDRESS. 3 WILMA WAY, CITY E HARWICH STATE MA ZIP 026451450 TEL FAX CELL EMAIL none • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 0 CIf_--4 IE • I ` M4 DATE \ ��a1� PER T# ��l c20_, 5 MAR 15 ,Q2$SI E ''DRESS G�CD- 2A OWNER'S NAME uct rn)Nos � �B��ILui LJEN DRESS �� TEL II s' \Glad FAX • L_' -' -rim -- PRINT UCGUF'A1LY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW: ❑' RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 211] APPLIANCES 7 FLOORS-9 BSM 1 2 3 4 5 6 7 8 • 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER DRYER FIREPLACE • FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER • ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER • 'v-esar— • INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Sa NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El AGENT ❑ I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# (,���'t3 SIGN URERE MP g MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME C.e,o p - CGA r�� „� _� ADDRESS , d _ c 9 3 ieT 6 CITY Proms STATE NV` ZIP Z(' .�/ TEL 5C.38 t(677-- OZOS FAX CELL$CI v 7 8CFJ f EMAIL