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HomeMy WebLinkAboutBLDG-23-004265 j -'`� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 141/4, CITY YARMOUTH MA DATE February 01,2023 PERMIT# BLDG 23 004265 JOBSITE ADDRESS 3 ST ANDREWS WAY OWNER'S NAME Dean Chouinard G OWNER ADDRESS 3 ST ANDREWS WAY SOUTH YARMOUTH MA 02664-2048 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:El 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 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 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 LESTER WADE LICENSE# 4569 SIGNATURE MP❑ MGF © JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD,22 CAPTAIN ISIAHS RD CITY COTUIT STATE MA ZIP 026352702 TEL FAX CELL EMAIL info anccipgenerators.com • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY c,v-wk.0 t&f '1 MA DATE 1-(5- '- PERMITS 2 3— 4 2(gC ,IOBSITE ADDRESS 3 s+. A-A e r4 u, s LA)a OWNER'S NAME .t e t, CA o ; n Qrve GOWNER ADDRESS SI et. abOVe TEI.So&-S-a(0- 3aloYFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ni PUNT CEARLY NEW:II RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO APPLIANCES 7. FLOORS-. BOA 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 ✓- GR LLE 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 INSURANCE COVERAGE I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES El NO 0 I EYOU CHEGI®YES,PLEASE INDICATE RETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILRY INSURANCE POUCY ® OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WA11VEt:lam 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 mks this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby oerffy that all of the details and informaEan I have subrnided or entered regarcling this applcation are hue and accurate to the best of laawiedge and that all plumbing work and Installations performed under the permit issued for this won wl9 be in compliance all P of the Massachusebs State Plumbing Code and Chapter 142 of the General Laws. C^ieds#—. T PLUMBER-GASFI i£R NAME Ls+e r Wade-ode- LICENSE# 4 5f0 I S RE MP 0 MGF® ,IP❑ JGF❑ LPGI❑ coRPORA11ON❑# PARTNERSHIP❑it LLC❑# COMPANY NAME Cape.Co et Tsncl_a n t7ei.c.�.r ADDRESS 2.3 Bo ee't in R. CITY Ikaskp e STATE MA zjP Cac04-9 Ta 50T-4-7-1--�tg FAX tokA CELL 50T-150-esvg EMAIL 111-�'cCA) p 9chits- +ors. co v