Loading...
HomeMy WebLinkAboutBLDG-23-005123 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kti,As CITY 'YARMOUTH MA DATE March 17,2023 PERMIT# BLDG-23-005123 JOBSITE ADDRESS 144 MONTAGUE DR OWNER'S NAME 'ELITE CONNECTION LLC• G OWNER ADDRESS 14 AIRLINE RD SOUTH YARMOUTH 02664-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 © 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 'Moses Joachim I LICENSE# 116677 SIGNATURE MP© MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION 0# I PARTNERSHIP ❑#' ILC ❑#I COMPANY NAME: IMOSES PLG&HEATING I ADDRESS. 1301 Buck Island Road, CITY 'West Yarmouth I STATE 'Ma I ZIP 102673 I TEL '7742511282 FAX I I CELL I I EMAIL 'mosesioa 1974(algmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' �'4� CITY -►1 i4 JV 1�1.+-,, � MA DATE -- 4 P "IvCI)1` `- Z3 "CO 5/2 3 JOBSITE ADgIRESS t., 4)1 GOWNER'S NAME e criewe l' LLL GVVNER ADDRESS C6---rn ' ��J ,Y u TYPE OR tt�� r TELSy g _FAy PFt)1�1T OCCUPANCY TYPE COMMERC�fAL 'I nos .�1� ��G�o CLEARLY DEDUCATIONAL ❑ RESIDENTIAL❑ NEW: RENOVATION: 2, REPLACEMENT:❑ PLANS SUBMITTED; YES 0 NO❑ APPLIANCES 1 FLOORS-. BSM 0©©® , 8 9 BOILER _�--- 10 ®® 13 14 BOOSTER ==n--� - CONVERSION BURNER semi _ COOK STOVE Ell ��� DIRECT VENT HEATER ---__-nil == DRYER C•••..._ �- -_ 1111ffiall111111am �_____FIREPLACCFURNACEFRYOLATOR iZgri�`m.ja.m nI i■i GENERATOR =®_= ��ETAIMM�NIMiltirtLPIMMES-Wi , GRILLE _ -�--= �� ►, �r' �1■INFRARED HEATER IM��I___ LABORATORYMall COCKS -=Nu m U 1 L D N PAR Malt. MAKEUP AIR UNIT _ -�_„LFJlIL�ls Mi llil POOL HEATER _�_ -__S ROOM/SPACE HEATER �_- • �_� -__ ROOF TOP UNIT Nallilli___ MINIM- UNIT HEATER _® ® -_ _ . ._111111 __®� WATER INVENTED ROOM HEATER �_ -- �� OTHER HEATER ___ =-- �_�--IIIII -_-- I have a INSURANCE COVERAGE -�_--�current liabIli insurance policy or its substantial equivalent which mts the requirements of MGL Ch.142 - I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW YES ❑ NO 0 LIABILITY INSURANCE POLICY OWNER'S INSURANCE WAIVER:I am aware that the Ii OTHER TYPE INDEMNITY El BOND, 0 • Massachusetts General Laws,and that my signature on this pe permit application waives this requirement.requiredt have the insurance coverage by Chapter 142 of the ''� SIGNATUR 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 accurate to the and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all ertinent provision Massachusetts State Plumbing Code and Chapter 142 of the Generalbest of my knowledge �? Laws, p on of the PLUMBER-GASFITTER NAME il4o515 4irra LICENSE#d 49? 'IGNATURE MP l� MGF 0 JP ❑ JGF❑ LPGI❑ CORPORATION 0# 1 PARTNERSHIP❑�� LLC 0 COMPANY NAME IWSLtiwfi ,PD fi n D ADDRESS��D( f�•cG^ (IQ 1.1sL(C�( CITY 4.D�C� ��LIQ� � p� FAX CELL �S/STATE_ =1- _ ZIP_ '' 2_ TEL o2 j/ (Z � Z X Z EMAIL_it � Cs)