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HomeMy WebLinkAboutBLDG-23-003320 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 14,202; PERMIT# BLDG-23-003320 j JOBSITE ADDRESS 11 JOHN HALLS CARTPATH VILL OWNERS NAME BEARSE SANFORD N G OWNER ADDRESS BEARSE MARCIA W 11 JOHN HALLS CARTPATH VILL YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Ej PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 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 0 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 David Whelan LICENSE# 13046 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DAVID A WHELAN ADDRESS. 152 schooner dr, CITY COTUIT STATE MA ZIP 026353423 TEL I FAX CELL EMAIL Idaveawhelanna,gmail.com • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r '�•�C � ` [ L .J 77" MA DATE /2 /! f L 332v / � 2� PERMIT# 4rLDEC 14 �T /�DDRESiS (l 3Di-1'✓ f{t�u CIZ�P���`f OWNER'S NAME 1�I1•iiJ- IZA►irspt'�z� OWNER ADDRESS TEL FAX T t3I�7oIRNG vEPARI MENT O_Gr 1PAANC.Y TYRE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[K CLEARLY NEW: [r RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES Z FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE j 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Rib ❑ 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 co 'mice w all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 1% i 0 n 1,4 i4 LICENSE# L-t 6 SIGNATURE MP L VMGF❑ JP El JGF❑ LPGI El CORPORATION®# 4 6 7 PARTNERSHIP❑# LLC❑# COMPANY NAME OP,'I 0 P Ps,t-i (Ad' IBC '%I'll}.Q I-- ADDRESS c S /D D W ? 0.12✓. CITY (y-.D STATE i P ZIP 026,S TEL 7 74'-2 2 fi Ga FAX CELL 7 79 2.5 2 b EMAIL'2+9✓rv"/-? G✓!'�i'I✓�� -) /14/4