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HomeMy WebLinkAboutBLDG-23-004779 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH MA DATE (February 28,2023 I PERMIT# BLDG-23-004779 JOBSITE ADDRESS 111 SHARON RD OWNER'S NAME (John Webster G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 1 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 (Andrew Leighton I LICENSE# 116130 I SIGNATURE MP© MGF 0 JP❑ JGF❑ LPG( ❑ CORPORATION 0#I I PARTNERSHIP ❑#I ILLC ❑#I I COMPANY NAME: IANDREW R LEIGHTON I ADDRESS. 120 Brewster Rd, CITY IW Yarmouth STATE IMA I ZIP 1026735706 I TEL I FAX I 1 CELL I I EMAIL Ihalloilcompanyta7.pmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =ut3�-" __:x CITY _ %/YlD -j _. _ MA DATE�' ,,,9 ?i PERMIT# Z (-1--)95 JOBSITE ADDRESSI__// Z __ _ I OWNER'S NAME J .� G OWNER ADDRESS I " /! ` I TEL, Ff .(�/ FAX s--...w. TYPE ORINT ROCCUPANCY TYPE -. COMMERCIAL LI EDUCATIONAL 0 RESIDENTIAL ---- CLEARLY NEW:[ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES Li NO[ APPLIANCES 1 FLOORS-' 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER — BOOSTER - ._. -Y._f , E __. F CONVERSION BURNER - SEL T= = - COOK STOVE _ ,` _:_ } _ _ ._. _(r illit ! ANTHTER �gig �CE , , FURNACE € 'wg1 t'' in'� �f- r GRILLEGENERATOR 01111 `' _ INFRARED E"..�'n ne- ' -- im a i , , ' HEATER r— -_ LABORATORY COCKS 1.__. _ __ i_ f_ _ _-- I III i MAKEUP AIR UNIT ' ' ,pal ..,,-----, OVENwing �aii-. i s POOL HEATER M1 Mt 1 •�. ....! , i-n-r f ROOM/SPACE HEATER 1111_11401M, 1 . 1, f }: r_"i .-iYa_1 .r I I ....... TEST i UNIT HEATER UNVENTED to• } 117.1 WATER HEATER .OTHER ! r -] INSURANCE COVERAGE _ _ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EA OTHER TYPE INDEMNITY Li BOND U f 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. CHECK ONE ONLY: OWNER ® AGENT Li SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this applicati are tru�and curs : o the'=st of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will a in comppttlanc with- Pertin, t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f PLUMBER-GASFITTER NAME ,dA t°[,¢.2 fee Csd�F rot_LICENSE#.teo( SIGNATURE MP 1721' MGF El JP® JGF 0 LPG'Li CORPORATION E# ) -/C,.'PARTNERSHIP 0#L ._ ____ LLC[#FT_ COMPANY NAME:l 1 /}. x G?!4 O . Zet,c, -. ADDRESS ,3. jsf_c J3�y CITY L .S'd, c 1lrn: I STATE :r /9JZIP - Lb C_ ,ITEL t. ", 'S$3 i FAX C`i =j CELL __.-.._ _... EMAIL ,�nf. _4lf0le+u_� ;r ,«'t/�, �c_tf __- - _J