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HomeMy WebLinkAboutBLDG-23-005061 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK akren BLDG 23 005061 I CITY YARMOUTH MA DATE March 15,2023 PERMIT# JOBSITE ADDRESS 4 RUNE STONE RD OWNER'S NAME YOBACCIO ROBERT J G OWNER ADDRESS YOBACCIO BARBARA 4 RUNE STONE ROAD SOUTH YARMOUTH MA 02664-1325 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:El 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 1 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 John Burke LICENSE# 15582 SIGNATURE MP© MGF El JP❑ JGF❑ LPGI ❑ CORPORATION El# PARTNERSHIP ❑#r LLC ❑# COMPANY NAME: JOHN J BURKE ADDRESS. PO BOX 866, CITY HANSON STATE MA ZIP 023410866 TEL FAX CELL EMAIL NONE ---. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j�t / -1 CITY �C�r"y�')d U f A MA OATS 3 {(-S 2-3 PERMIT# of to JOBSITE ADDRESS LI X"1 z S/ -we 1 C/ OWNER'S NAME /,`/ G OWNER ADDRESS 5/4 ► ( TE I��GO FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENTZjN PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 FLOORS-. 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE - I - DIRECT VENT HEATER DRYER - _ FIREPLACE - FRYOLATOR . FURNACE GENERATOR 4 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST /- - . UNIT HEATER - _ UNVENTED ROOM HEATER WATER HEATER 1 OTHER 1 INSURANCE COVERAGE , I have a current tiabil(ty insurance policy or its substantial equivalent which meets the requirements of MM.Ch.142 YES►LJ NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILUTY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee doe;not have the insurance coverage required by Chapter 142 of the Massachusetts Gene al Laws,and that my signaturson this permit applicationwives#hie;requirement CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT I1 aresiy certify a1 a(the de#a and iniormaiion wave subm tted or entered regarding this application are true and accurate t he-best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in ' all Riven# Massachusetts State Plumbing Code and Chapter 142 of the General laws. provision of the PLUMBER-GASFITTER NAME LICENSE#J SSE SIGNATURE MP L MGF❑ JP❑ JGF 0 J a LPGI❑ CORPORATION❑# / PA�RTTNEERSHIP❑# LLC 0# COMPANY NAME 14 )3tcrLe 07 g/lJ ADDRESS /3 /- -? 1/5 St ciTY ila C ALV 2 STATE I�n ZIP 5 3 S TEL?T/ )01V- y3s FAX CELL EMAIL