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HomeMy WebLinkAboutBLDG-22-004671 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F w -°` CITY 'YARMOUTH MA DATE February 23,2022 PERMIT# BLDG-22-004671 li Er JOBSITE ADDRESS 168 LILY POND DR OWNER'S NAME (Donna Goggin G OWNER ADDRESS 68 LILY POND DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 GENERATOR 1 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 0 OTHER OF INDEMNITY 0 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 (Brian Springsteen LICENSE# 12593 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! El CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: IBRIAN E SPRINGSTEEN I ADDRESS. 13 WILMA WAY, CITY IE HARWICH STATE MA ZIP 1026451450 TEL I FAX 1 CELL I 1 EMAIL Inone CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j r 4r. I " E D -CITY r NO LW-N. MA DATE F c�-�d4— PERMIT# FEB 23ANTE DD ESS Lod \N r� . )� OWNER'S NAMEor\r\C �OV\ 1 Bust G DEi +�EPrf ID coS �0.�L— TEL—I1i1"elgtk-CIVIC) FAX B PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL V CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO' APPLIANCES 1 FLOORS—I 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 ROOM/SPACE HEATER . ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER QTHE e INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Sa NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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. 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 the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 6Z I(/4_ ,2 A LICENSE# 1/1.5 cis SIGN URE MP X MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# Lc❑# COMPANY NAME Ceitp o C GA i)r c,-ip e y, -C ADDRESS L.o _ Ci'}C g 3 oe r 6 CITY Pr STATE �v`Vk ZIP p?��s 7 TEL $G g L( [ S FAX CELLSO©, 72.I�U Cf EMAIL