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HomeMy WebLinkAboutBLDG-23-004281 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kr, CITY 'YARMOUTH-740 MA DATE (February 02,2023 PERMIT# BLDG-23-004281 JOBSITE ADDRESS 180 COOLIDGE RD OWNER'S NAME (Eduardo Neto G OWNER ADDRESS 80 COOLIDGE RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT El 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 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 1 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 (Anson Celin I LICENSE# 132655 I SIGNATURE MP 0 MGF ❑ JP© JGF❑ LPGI 0 CORPORATION 0#I I PARTNERSHIP ❑#I ILLC ❑#1 I COMPANY NAME: IANSON CELIN J ADDRESS. 126 Capt.Blount Rd, CITY (South Yarmouth I STATE IMA I ZIP 102664 I TEL I I FAX I I CELL I I EMAIL Iansoncelin(a7yahoo.com I lid MASSACHUSETTS UNIFORM APPLICATION fFOR A PERMIT TO PERFORM GAS FITTING CITY FVt,��-- WORK ,s ' ----_t'I f/" "'G� MA DATE - I - 23 JOBSITE ADDRESS�Q ('C�,l � f a PERMIT� Z3 ^ �Z�/ G41i OWNER'S NAME OWNER ADDRESS_ -li G -Z TYPE OR ��-i'�'�FAy pr. g OCCUPANCY TYPE COMMERCIAL 0 CLEARLY EDUCATIONAL 0 RESIDENTIAL[ NEW:[] RENOVATION: REPLACEMENT:❑ APPLIANCESPLANS SUBMITTED: YES D NO BOILER FLOORS-4v®B®©® Ilk BOOSTER CONVERSION BURNER allillram.11.11.1111ralaMMEMIllal ® ® 13 t R DIRECT VENT HEATER mollilla-�- == -- DRYER =--�- -�_- FIREPLACE __-� FRYOLATOR - (13 GRILLE =-== _Mall Mill Ill � ,...... INFRARED HEATER MIN all 1111111111111111 Mill Nil LA -�- MAKEUP OR UNRY OCKS IllIl - === POOL HEATER == �-_ __ ROOM I SPACE HEATER _ ROOF TOP UNIT �� _� MINIT UNIT HEATERMMIIIIMMIMIII1M111.M aiili aa11101lal111il1i116111111111,11101,.1.11.111 - ----- UNVENTED ROCaM HEATER - _ aaiNATER HEATER =-- _ alai v..v...,.. GE I have.a currentINSURANCE--�-©fiatIll insurance policy or its substantial equivalent whicOh meets the requirements of MG _ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATECh.142 YES NO BOXDEL4W 0 LIABILITY INSURANCE POLICY OWNER'S INSURANCE WAIVER: OTHER TYPE INDEMNITY ❑ I am aware that the licensee does not the insurance coverage required by CCha[3 tO • Massachusetts General Laws,and that my signature on this permit application waiv es this requirement. p 142 of the .� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER I hereby certify that all of the details and information I have submitted or entered regarding 0 AGENT 0 Iand e a that all plumbing work,and installations performed a e be permit Massachusetts State PlumbingCodep mit issued for this �pp�cation application be in co true pl ante with all Pertinent best of 4 andperformed Chapter ed of the PLUMBER-GASFIT'fER NAME General Laws. my knowledge ��U�'1 } t provision of the [_e O rN MP 0 MGF� JP LICENSE#3��- IGF❑ LPGI 0 CORPORATION 0# SIGNATURE COMPANY NAME Ce II:1 w"I PARTNERSHIP[] wnb�� u-c❑�t CITY A STATE ADDRESS FAX FAX I� ZIP ^�`� G�f CELL TEL _Z� I G2 EMAIL Kt i k1/40-