Loading...
HomeMy WebLinkAboutBLDG-23-003655 #388 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w' V� CITY IYARMOUTH MA DATE January 05,2023 PERMIT# BLDG-23-003655 JOBSITE ADDRESS 1388&390 NORTH MAIN ST I OWNER'S NAME IBENOIT MARY JANE G OWNER ADDRESS 154 WINTER ST HANOVER MA 02339 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT 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 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❑ 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 IBRADLEY TOMASETTI LICENSE# 116544 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ITOMASETTI PLUMBING ADDRESS. 1103 UNION ST, CITY IYARMOUTH PORT STATE MA ZIP 102675 I TEL I FAX 1 CELL 1 EMAIL Itomasettiplumbinp[7a,gmail.com '' _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 19 �` .. CfT`(� rw r�,, l MA DATE /�//ZdZ3 PERMIT# L3- 3 i. s� JOBSITE ADDRESS f 4 ,,,,.,...,- OWNERS NAME nk (....142_ . OWNER ADDRESS TEL TYPE OR FAX PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Efr*"....- CLEARLY NEVJ;❑ RENOVATION: ❑ REPLACEMENT: g-***---- PLANS SUBMITTED: YES ❑ NO❑ APPLIANCES 1 FLOORS-+ 8slu1 1 9 3 1 5 6 BOILER 9 11 11 12 13 1 BOOSTER CONVERSION BURNER COOK STOVE ' DIRECT VENT HEATER DRYER �j FIREPLACE FRl'C!LATOR _____1FURNACE —`— GENERATOR GRILLE INFRARED HEATER LABORATORYCOCKS MAKEUP AIR UNIT -- OVEN POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT 1 -� TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER —T-- INSURANCE COVERAGE I I have a current liab€li insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ®'f16- I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y 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. SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER ❑ 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 myknowledge ` - 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 `Z P Laws. PLUMBER-GASFITTER NAME 5<-4,J �k„74 S eyily - LICENSE# /�s-yy SIGNATURE MP MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑ft PARTNERSHIP❑0 LLC❑ COMPANY NAME boa%t c 1 ' �I L,_ ADDRESS_ f/ - CITYX e L 14 igy71-- STATE A ZIP 15Z 67S-- TEL FAX CELL 4-0$4`5L2-T1100 EMAIL To,,,