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HomeMy WebLinkAboutbldg-23-003429 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK " CITY YARMOUTH MA DATE December 20,202; PERMIT# BLDG-23-003429 a. E JOBSITE ADDRESS 71 CHIPPING GREEN CIR OWNER'S NAME Frank Fiorello G OWNER ADDRESS 71 CHIPPING GREEN CIR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:ID PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS-F 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 I SPACE HEATER ROOF TOP UNIT TEST 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 !Vincent Marino LICENSE# 15136 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: THOZ GUYS ADDRESS. 67 Sunny Ave, CITY !Webster STATE MA ZIP 01570 TEL 15088852378 FAX CELL 1 EMAIL Imaddy(cilthozquysinstallations MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK --t i "e CITY S VOINNA0 LA-k MA DATE 11 C.4 1 ,ripPERMIT# JOBSITE ADDRESS f I Ch\�p h3 �,vice e r CV OWNER'S NAME �Ct��C. -P-tore I t lO GCtYI')e.� TEL OWNER ADDRESS 1r�l p� �Sg TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL[ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[/ PLANS SUBMITTED: YES❑ NO[l APPLIANCES 1 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 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [2(NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW c} S0 LIABILITY INSURANCE POLICY [�/1 OTHER TYPE INDEMNITY ❑ BOND El �j 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 Er 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 the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. tLiAtRrN'' - PLUMBER-GASFITTER NAME U i n -* “Ct'C' AO LICENSE# I S 13tQ SIGNATURE MP[ MGF❑ IJP El JGF❑ LPGI❑ CORPORATION('#4Sc?.0 PARTNERSHIP❑# LLC #❑ COMPANY NAME/ (,-�V�S Tnsicit/Gl+' S 'rhC• ADDRESS t4C2 - O Yl YI I V' � _ ,� ttSTATE `` ZIP S (TEL��l` ��(Q ' 9 ►QC) CITY Me bs`� Ivt.� �?� FAX CELL EMAIL MaOOd 1tork-i .Cohi