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HomeMy WebLinkAboutBLDP-23-004224 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lk.,, CITY YARMOUTH MA DATE January 30,2023 PERMIT# BLDP-23-004224 JOBSITE ADDRESS 157 CAPT NICKERSON RD OWNER'S NAME HARRINGTON DAVID J G OWNER ADDRESS HARRINGTON MARY A 157 CAPTAIN NICKERSON RD SOUTH YARMOUTH MA 02664 TEL 174 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:al PLANS SUBMITTED: YES ❑ NO 111 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 , UNIT HEATER , UNVENTED ROOM HEATER , WATER HEATER 1 , 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 Peter Jones LICENSE# 13577 SIGNATURE MP El MGF 0 JP❑ JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: (Peter Jones Plumbing&Heatinq ADDRESS. 6 Chickadee In, CITY (west varmouth STATE MA ZIP 026731111 TEL FAX I CELL 5082375207 EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 1/30/23 PERMIT# BLDP-23-004224 lig JOBSITE ADDRESS 157 CAPT NICKERSON RD OWNER'S NAME HARRINGTON DAVID J P OWNER ADDRESS HARRINGTON MARY A 157 CAPTAIN NICKERSON RD SOUTH YARMOUTH,MA TEL 02664 174 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURES .i FLOORS—. BSM 1 _ 2 , 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING 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 m OTHER TYPE OF INDEMNITY 0 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'S NAME Peter Jones LICENSE 1/3577 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Peter Jones Plumbing&Heating ADDRESS 6 Chickadee In CITY west yarmouth STATE MA ZIP 026731111 TEL FAX CELL 5082375207 EMAIL