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HomeMy WebLinkAboutBLDG-23-001010 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '�' °� CITY IYARMOUTH MA DATE (August 25,2022 PERMIT# BLDG-23-001010 JOBSITE ADDRESS 19 ACADIA RD I OWNER'S NAME 'JAMIESON PHILIP D JR G OWNER ADDRESS IJAMIESON DONNA M 9 ACADIA RD WEST YARMOUTH MA 02673 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL III PRINT PLANS SUBMITTED: YES El NO❑ CLEARLY NEW: ElRENOVATION:❑ REPLACEMENT:El 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 1 ' 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 1 OTHER DESCRIPTION:underground line 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 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 'Andrew Hayes I LICENSE# 116489 I SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPGI ❑ CORPORATION❑#I I PARTNERSHIP 0#I ILLC 0#1 COMPANY NAME: (PLUMBING SOLUTION BY HAYES I ADDRESS. 122 Rustic Lane, CITY 'Hyannis I STATE IMA I ZIP 102601 I TEL ' I FAX I I CELL 17747225013 I EMAIL 'PLUMB HAYES910YAHOO.COM I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GNY Oa yir O+L MA DATE 81?'`j JVj_ PERMIT# Z 3 `" / 6/6 'UG 2022 JOBSITE ADDRESS 9 iko :.lc, jz 2,4,1, OWNER'S NAME 41 Di Lac,P6I DN1INER ADDRESS q ti-cA`ch. ita,a- TEL a5s-S 11'/1i9 FAX BUILIIING DEPARTNENT Bye QR ;,IPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2/ CLEARLY NEW:(y RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 11 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE t FRYOLATOR FURNACE GENERATOR • GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _ i POOL HEATER { ROOM I SPACE HEATER ROOF TOP UNIT TEST -.. ... ._ .... . _ . . . . ._ ...._. __..._ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER) OTHER V vie eel rID0net t - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL.Ch.142 YES IYNO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE II4DEMidITY ❑ 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. CHECK ONE ONLY: OWNER 0 AGENT 0 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 a e to the best of my knowledge j- and that all plumbing work and installations performed under the permit issued for this application will be in complianceall Pertinent provision of the `` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Lu PLUMBER GASFITTER NAME ArareAA) I40-0,-- LICENSE#14 Ifl SIGNATURE MP E MGF❑ JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME Pt ilt ib (i Spik*iges 13 j 44 ADDRESS P4 Pudic lam'^ CITY 14- 0knr STATE N V ZIP 0 -ti0 t TEL FAX CELL I Y- 2:2-- 6—D/3 EMAIL eio M..., tn0.0 .riGlob. car►