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HomeMy WebLinkAboutBLDG-23-004071 ram.* MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK if CITY IYARMOUTH MA DATE (January 24,2023 'PERMIT# BLDG-23-004071 �� JOBSITE ADDRESS 128 LAKE RD I OWNER'S NAME 'Gary Bianco I G OWNER ADDRESS 128 LAKE RD WEST YARMOUTH MA 02673 l TEL' ( TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS--I 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/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❑ 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 'Andrew Leighton I LICENSE# 116130 I SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! El CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑# COMPANY NAME: 'ANDREW R LEIGHTON I I I ADDRESS. (20 Brewster Rd, I CITY 'W Yarmouth I STATE IMA I ZIP 1026735706 I TEL I I FAX I I CELL I I EMAIL Ihalloilcompanyna,gmail.com MASSACHUSETTSFOT., T-=;= UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =_gin='a =uGi= � CITY 1::: — MA DATE Irif i 7 4 PERMIT# 2 3 4--°?/ JOBSITE ADDRESS_ ,L -act I OWNER'S NAME OWNER ADDRESS *r-- n C - 1 TYPE OR --- rl: W — SI P- 9G 27 FAX ,--� PRINT OCCUPANCY TYPE COMMERCIAL . yV'- "-"�' CLEARLY © EDUCATIONAL Q RESIDENTIA 1►,� NEW ( RENOVATION:Q REPLACEMENT:(� APPLIANCES'1 FLOORS PLANS SUBMITTED: YES Not►' BOILER©© 4 as 6 mum g to BOOSTERWig W MI� �s 14 F CWriMONVERSION - COOK STOVE f -III BURNER MIIIIIIII DIRECT VENT HEATER �_ � _ r— = DRYER ==--;. �. Wl IINIZEimummimmiM FRYOLATOR !WWWITILMIWIMMatil ( j FURNACE -- W: = f GENERATOR ; 1 ._- r - J�-�.�- 'INFRAREflH UlthiirkligillighatUNLIMITI."Mggill41= LABORATORY COCKS _ �� � � m + OVEN f i POOL HEATERuntipsw rj� ROOM/SPACE HEATER wroitomiwwwwi f teli ROOF TOP UNIT �--- ` lit,` ; . :( utirfl ; luiluvinmommommi..-1115-1111.1111111.11.1.11111.111111-W-, ,W,11— 11 :11-Mar-ft- 1"11- - --1-: - -"IiLlif.Ma-11, 1111 UNVENTED ROOM HEATER ---L-,:---;::--w----,mzg-,MfTmramr -ww-_ ,.,__-_--o_m_zi,aa OTHER ' = jW iimW111.$0011.11.... WININIE - - iliitt I have a current frabilitKinsurance policy or its substantial eqS vR ANC t ichCOVERe s the requirements AGE i ' I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 142 YES 0 NO Q LIABILITY INSURANCE POLICY 5 OTHER TYPE INDEMNITY 0 BOND -. OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required b Massachusetts General Laws,and that my signature on this permit application waives this requirement y Chapter 142 of the tSIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Q AGENT Q e 1 hereby certify that all of the details and Information I have submitted or entered regarding this appticali• arelru and - cura and that all plumbing work and Installations performed under the permit Issued for this application will.a in camp aanc=with- Pertin Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ppa the' st of my knowledge = t provision of the PLUMBER-GASFITTER NAME A Pte:> r'Gi" LICENSE# t MP FA, MGF Q JP Q JGF 0 LPGI SIGNATURE Q CORPORATION Ee# 3��y e PARTNERSHIP 1—j#COMPANY NAME: X O!G C6 _ LLC # fie-- ADDRESS �f��. j3 CITY � - �.. ._ y.---...�.�._.., STATEmmulvt_ ZIP C:>�,- C TEL FAX •, Gt CELL EMAIL - z EMAiL L/�//.-•i i�.c-frrru:s�:.�, �'�/��. �.s Y i`off,