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HomeMy WebLinkAboutBLDG-22-005815 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH MA DATE 'April 12,2022 PERMIT# BLDG-22-005815 E I( _w JOBSITE ADDRESS 159 CARVER RD OWNER'S NAME (James Toomey G OWNER ADDRESS MA 02062 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT PLANS SUBMITTED:YES El NO 0 CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:El 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 El 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 (Gregory Selfe I LICENSE# 126714 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC 0#1 COMPANY NAME: 'GREGORY A SELFE I ADDRESS. 141 SPRINGER LN, CITY (WEST YARMOUTH I STATE MA ZIP 1026734930 I TEL I FAX 1 I CELL 1 I EMAIL 1 _` - ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING 1, WORK CITY ( ov MA DATE Alt• Z-d- PERMIT 21- c rr 1- JOBSITE ADDRESS S 9 CAAYri. 1 OAt) OWNERS NAME Dori G - Y OWNER ADDRESS S4 CAevelt ROA.. TE•r)Tn.476a' FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL RI Y!IAT CLEARLY NEW:❑ RENOVATION:W REPLACEMENT; ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 SSM 1 2 3 1 5 6 7 0 BOILER 9 10 11 12 13 1 R BOOSTER I 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 AP' 1 TEST ... UNIT HEATER . BUILDI !�E'I;Art tv,EN i • _._ INVENTED ROOM HEATER aY �'— WATER HEATER ,_____- OTHER _ T • 1 INSURANCE COVERAGE I have a current kalEtLinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [g NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY tl 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 AGENT CHECK 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 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. L1 PLUMBER-GASFITTER NAME gAEy st LICENSE#ad7y SIG & NATURE MP ❑ MGF❑ JP (fit] JGF El LPG' ❑ CORPORATION❑# PARTNERSHIP❑ LLC❑# COMPANY NAME 6cE6o,ey S-tif,c P c fw ADDRESS et SPR.in be c. 49-fic CITY &v. Yitit 044 STATE "M ZIP 0"71 TEL ).>Zg lint( FAX CELL&(?).-r-n-1(I3 V EMAIL S.GieetI'iq t.74r{,4 t•ev+