Loading...
HomeMy WebLinkAboutBLDG-23-002397 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK wBLDG-23-002397 w e CITY 'YARMOUTH MA DATE November 01,202. PERMIT# r 1, JOBSITE ADDRESS 171 ARROWHEAD DR OWNER'S NAME IOLIVA FRANCIS A G OWNER ADDRESS OLIVA MARY J 71 ARROWHEAD DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ 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 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 1 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 !Michael Saurette LICENSE# 134174 I SIGNATURE MP 0 MGF ❑ JP© JGF❑ LPGI 0 CORPORATION 0#I I PARTNERSHIP 0# LLC 0#I COMPANY NAME: ISAURETTE BROTHERS I ADDRESS. 17 Bamhouse Road,7 Bamhouse Road CITY IDennisport I STATE Ma. ZIP 102639 I TEL I FAX 1 1 CELL 1 I EMAIL Irsox555na,gmail.com .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK osN CITY KC(I IM�U ` i'1 po II� MA DATE �CT E .•0-LL—7.4 PERMIT#JOBSITE,ADDRESS 7( Aii011/ k e61.4 D I oZ7$ - ►' OWNER'S NAME 1K/1►'GI,S U/1G G� OWNER ADDRESS /7 ,r--- TYPE OR TEL �I 3 SNIJ Sg7 FAX PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIACLEARLY NEW:❑ RENOi/ATIONN REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NQ- APPLIANCES ti FLOORS said 1 2 37 5 6s y to 11 12 BOILER BOOSTER CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER DRYER _ FIREPLACE �- FP,I'CiLATOR 1 FURNACE ,X --- GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS __-1__�__ MAKEUP AIR UNIT • OVEN POOL HEATER I • �Ii ROOM I SPACE HEATER ROOF TOP UNIT TEST i UNIT HEATER —j UNVENTED ROOM HEATER WATER HEATER X OTHER HEf, INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ja 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 Massarhus.et • G fera6 aws, %at my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER ❑ AGENT El 'r.l-• 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 `1` and that all plumbing work and installations performed under the permit issued forthis 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 LICENSE# i H 3 L1 SIGNATURE MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑#E PARTNERSHIP El# LLC❑#€: COMPANY NAME Weft( \3 j ADDRESS 7 t,�1rh )c fir( l�nmif� CITY - 001 fibri-- STATE�' f ZIP 00' 63� TEL 7741 Y.7 `p'Y�f, FAX CELL l ! 7 n7o r- EMAIL R,SO Scs6Y44r f.awl