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HomeMy WebLinkAboutBLDG-21-007332 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7 CITY YARMOUTH MA DATE June 16,2021 PERMIT# BLDG 21-007332 tI p JOBSITE ADDRESS 176 BEACON ST OWNER'S NAME tai chan G OWNER ADDRESS 176 BEACON ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 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 ❑ 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 Robert Reid LICENSE# 32698 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ROBERT H REID ADDRESS. 1397 OLD BASS RIVER RD, CITY SOUTH DENNIS STATE MA ZIP 026602779 TEL FAX CELL EMAIL 1 . --,.. '� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORMGAS FITTING WORK F"" . . Arft 10A, DATE 6'13 —ad d / PERMIT A JO IT ADDRESS 1-1( 'Sec.C,o r'- sr OWNERS NAME '11W ) c rn 'l. ;bWIIIER ADDRESS /1(2 C =34.,co'- SEC- TEL I-7gf/-3 L 6-1 t FAX B �;;t, .,,; OP P. I`JCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E LE RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-I FLOORS-{ BSM 1 2 3 1 5 6 7 6 9 10 1'1 12 1; 14 BOILER —I BOOSTER CONVERSION BURNER, l COOK STOVE 1 DIRECT VENT HEATER i DRYER I FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT _ OVEN I POOL HEATER X. . ROOM/SPACE HEATER ROOF TOP UNIT TEST . UNIT HEATER r UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE tE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I j i OWNERS 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 ❑ 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 tl";e i `JtMassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAM: LICENSE# `3c26/18— SIGNATURE MP ❑ MGF In JP LJ JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#i COMPANY NAME RL►k ?lam-fv\\oirnC, ” ADDRESS \ -',t v\A 9 R CITY 3 O ykNtntiocid . STATE Mk ZIP 41'3.-tsaG2- TEL Sots-an 't 1110 FAX CELL L $ a-31 7((& EMAIL 4 / !r4-457 a co 40/: fte_