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HomeMy WebLinkAboutBLDG-23-004122 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK mI CITY YARMOUTH MA DATE January 25,2023 PERMIT# BLDG-23-004122 JOBSITE ADDRESS 162 OLD MAIN ST OWNER'S NAME Carla Sharron G OWNER ADDRESS 162 OLD MAIN ST SOUTH YARMOUTH MA 02664-4524 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: m 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 El 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 Joshua Canino LICENSE# 30034 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JOSHUA A CARLINO ADDRESS. 108 CAPN CROSBY RD, CITY CENTERVILLE STATE MA ZIP 026321606 TEL FAX CELL EMAIL awesomequvsplumbingAgmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4 MA DATE PERMIT# Z:3— 4 12 Z- 5 C,_. JOBSITE AD RE S I O )d CCt r 1 C1 OWNER'S NAME JAN �tPvi DD E TEL FAX S 4OR [- a LNG SAY E COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL NEW:❑ RENOVATION:, REPLACEMENT: ❑ PLANS SUBMITTED: YES NO 0 APPLIANCES 1. FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER, --i COOK STOVE - DIRECT VENT HEATER DRYER --1— FIREPLACE i FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER • ROC)M I SPACE HEATER ROOF TOP UNIT TEST • . . ---. . . . . . ..- • _ .._.... • .._ -- UNIT HEATER - INVENTED ROOM HEATER WATER HEATER OTHER . 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ,Z NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (I OTHER TYPE INDEMNITY ❑ BOND LI 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 4' 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 co pliance wi II Pectin rovlsion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. dff PLUMBER-GASFITTER NAME jai"))")) vcb�'cx ��`� LICENSE#3Qa3 GNATURE MP❑ MGF❑ JP IGF❑ LPGI ❑ CORPORATIONfI El# PARTNERSHIP❑# LLC❑# COMPANY NAME 1 <fa� �j��/ yyJA, DRESS /qv,/ kni-n,I)Q 1✓/(tJ� CITY SOUS �y4 1 c C f I) / STATE M ZIP t�7 ;�— c 9- TEL 5 7 a-3 r_333 FAX / CELL EMAIL "' �Sr�m� v 1 un14.0