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HomeMy WebLinkAboutBLDG-23-004805 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4 CITY YARMOUTH MA DATE March 01,2023 PERMIT# BLDG-23-004805 t; JOBSITE ADDRESS 185 SEAVIEW AVE OWNER'S NAME GEORGE NORWOOD G OWNER ADDRESS KELLY NORWOOD 69 PINE TREE DR METHUEN 018440000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO ID 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 1 • 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 1 • 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 0 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 Kosta Laci LICENSE# 16529 SIGNATURE MP 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: KOSTA LACI ADDRESS. 612 WASHINGTON ST, CITY BRAINTREE STATE MA ZIP 021845755 TEL FAX CELL EMAIL _ --ti --- MAsAcHusl=rrs UNIFORM Are `��`G AS- �S II-- PLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK RID . iCatr(MOv VI MA DATE - P_ 23-DO1. . JO SI ADDRESS r8) S P,r, y t / �q� M� 1 20 OWNER'S NAME E•ADDRESS B U I I � R t �P NCY TYPE c TEL FAX By lk ---- COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL CLEARLY Gkr NEW:M RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 FLOORS ®0 BOILER --��E= 6 7 9 10 �® io 14 BOOSTER --- =— --� CONVERSION BURNER, �� - �= C DIRECT VENT I! � � IIIIII -- DRYER EATER --=�== -- FIREPLACE nell,_C� --- FP,YOLATOR C., suriziainar,N-•-••.GEN ==-=- _--_ innollill GRILLE -�-�--_ _��_- INFRARE_ry HEATER �_ -� ,,, LABORATORY COCKS -own�-=-ma _-=- MAKEUP AIR UNIT IIIIIIIIIII NM In ir2)lgL HEATERllIllIllIlliIllIllIln �___ ____� ROOM SPACE HEATER = -_ =®_ 1111111 _ ROOF TOP UNIT 1111111111111111 _- __En - IINVEIJTED ROOM HEATER 11•1111_--_== WATER HEATER r OTHER ME___ __-__ - _-_ 1 -_1 _ -_C_ 1......................._____11111•111mminami 111111 all WI 1111111111111 I have a _-�C --M--�� current frabili insurance policyor its substantialCOVERAGE -� equivalentvrhich meets the requirements of MGL.Ch.142 YES AZ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY ZE OTHER TYPE INDErJ9NITY ❑ 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 CHECK ONE ONLY: OWNER 0 AGENT 0 -• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a and that all plumbing work and installations performed under the permit issued for this application will be in co Massachusetts State Plumbing Code and Chapter 142 of the General Laws, urate to the best of my knowledge �' i P a e 'fh all Pertinent provision of the PLUMBER-GASFITTER NAME KdS4 L.\C I' LICENSE#1 6 2 1 SIGNATURE MP 0 MGFJP❑ JGF 0 LPGI 0 CORPORATION❑ COMPANY NAME (U�b� PARTNERSHIP❑�� Lc❑ 4-4, LLC ADDRESS CO W CITY �R � 71 STATE. ZIP O Z 8' l[ TEL 33 6' �7 FAX ( CELL EMAIL C( -'°