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HomeMy WebLinkAboutBLDG-23-004109 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '4_ CITY !YARMOUTH ry BLDG-23-004109 MA DATE 'January 25,2023 PERMIT# JOBSITE ADDRESS 12207 HEATHERWOOD OWNERS NAME EDMAN NATALIE H TR G OWNER ADDRESS NATALIE H EDMAN REV LVG TRUST 2207 HEATHERWOOD YARMOUTH PORT MA TEL I 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT 111 CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 ❑ OWNERS 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 'Paul Gorgone LICENSE# 20873 SIGNATURE MP❑ MGF ❑ JP© JGF El LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: PAUL R GORGONE ADDRESS. PO BOX 1566,11 FROG TREE LANE CITY 'EAST DENNIS STATE MA ZIP 026411566 TEL I FAX CELL EMAIL paulgorponeRpmail.com d'`"' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ti Rm.i MA DATE l5 0-3 PERMIT# JOBSITE ADDRESS ' Aa0 -7 1k,�)N_ .Q,- c,d Gh✓OWNER'S NAME A.,_-_,_, e,i- ' ' _n G OWNER ADDRESS 5�k—ram. Q TEL TYPE OR FAX PRINTOCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-.l FLOORS--F sSM 1 BOILER 15 6 7 ° 9 10 I'I 12 I; 1 4 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER - DRYER FIREPLACE FRYDLATOR Mill FURNACE t - GENERATOR illini GRILLE INFRARED HEATER LABORATORY COCKS ; MAKEUP AIR UNIT OVEN POOL HEATER ROOM;SPACE HEATER. INN ROOF TOP UNIT TEST UNIT HEATER Uf�VENTED ROOM HEATER Il. 1 INE_________I WATER HE,7l HEATER t ■ OTHER 1.111111111111111111.11111111111........ M M:� IIIIII I E I have a current liabili insurance policy or its substantial equivlent v hicDhVm�s the requirements of NIGL. l I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Ch.142 YES [-_ -NO ❑ LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND OWNER';INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required b ter142 Mass�achuset r3eral I . rid that my signature on this permit application waives this requirement. y Cha p of the 3 f SIGNATURE OF OWNER OP,AGENT CHECK ONE ONLY: OWNER ❑ AGEN Cl-- I hereby certify that all of the details and information I have submitted or entered regarding this application are true and that all plumbing work and installations performed under the permit issued for this application will be in complianc with II Pe �' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. and a rate to the best knowledge v provision I the PLUMBER-GASFITTER NAME LICENSE#5oi? SIGNATURE MP ❑ MGF❑ JP [}—j'-GP❑ LPG! ❑ CORPORATION ❑ F PARTNERSHIP 1P❑�� LLC❑31: COMPANY NAME_eg „�y�,� p ADDRESS— . � — CITY � . 3 FAX STATE V1 a4— ZIP TEL 78- 51)Z CELL .� EMAIL