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Home My WebLink AboutBLDG-23-003260 ;- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k:t. t CITY 'YARMOUTH.,,,,, I MA DATE (December 12,202;PERMIT# BLDG-23-003260 JOBSITE ADDRESS '15 MINNETUXET WAY OWNER'S NAME IRYAN THOMAS G JR G OWNER ADDRESS IRYAN KRISTIN L P 0 BOX 148 YARMOUTH PORT MA 02675 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL III CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES ❑ NO❑ 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/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 1 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 'Gregory Selfe I LICENSE# 126714 I SIGNATURE MP❑ MGF 0 JP El JGF 0 LPG( ❑ CORPORATION❑#I I PARTNERSHIP 0#' i_LC ❑#I COMPANY NAME: 'GREGORY A SELFE I ADDRESS. '41 SPRINGER LN,41 SPRINGER LN CITY 'WEST YARMOUTH I STATE 'MA I ZIP'026734930 I TEL I FAX I I CELL I I EMAIL Iselfegregna,yahoo.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -c k ,�,�w� CITY YA RY18A MA DATE /off-la-cia, "L" — 3 Z(-I)PPERMIT# JOBSITE ADDRESS /S m inn di.X e1 1!//4 y OWNER'S NAME / y G OWNER ADDRESS ! S tri 1 Y) n �'h'X d &Jf", TE Sack Tee-476a. FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(1 CLEARLY NEW:❑ RENOVATION: O. REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-4 ' 61� 1 2 ' ° 9 10 11 12 nth 1 BOILER 3 4 5 6 1`' i BOOSTERI —� CONVERSION BURNER I _ I COOK STOVE DIRECT VENT HEATER f DRYER —� FIREPLACE `---; FRYOLATOR FURNACE • _ ,________I GENERATOR _� GRILLE _� INFRARED HEATER i LABORATORY COCKS {�—i MAKEUP AIR UNIT r OVEN I POOL HEATER I---____ ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I�11 INSURANCE COVERAGE 1 - 1 I have a current lia j i insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ®'NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ID LIABILITY INSURANCE POLICY X 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. v '� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El] AGENT ❑ 'lc, 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 `',` 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. knowledge LI) PLUMBER-GASFITTER NAMEete'(, goal,Tel& LICENSE t+vZb?ay ___ __,c'ION RE MP❑ MGF❑ JP [i JGF❑ LPGI ❑ CORPORATION❑IIPARTNERSHI P❑# LLC COMPANY NAME st ile fit' ❑ san Rnrs ADDRESS Y( See rn6roe. ZA.,fc CITY Gv. �-krn.� �q ZIP CA-6 73 STATETECSof?)`�7$. /Y3 FAX CEL 1/4g.1Q.It13ly EMAIL g (iFr /ei a yj4.hux Co"