HomeMy WebLinkAboutBLDG-21-005279 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
9 CITY IYARMOUTH MA DATE March 15,2021 PERMIT# BLDG-21-005279
JOBSITE ADDRESS 66 POND ST OWNER'S NAME CHU WILLIAM W TRS
G OWNER ADDRESS CHU VIVIAN K TRS 20 TREMONT ST WINCHESTER MA 01890 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
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
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 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-GASFITTER NAME Moses Joachim LICENSE# 16677 SIGNATURE
MP El MGF 0 JP❑ JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑#I
COMPANY NAME: MOSES PLG&HEATING ADDRESS. 301 Buck Island Road,
CITY (West Yarmouth STATE Ma ZIP 02673 TEL 7742511282
FAX I CELL EMAIL mosesjoa1974@gmail.com
1:". I ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
I:'4f_su CITY � MOCt J 2
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MA DATE D `� PERMIT Q�flG l 2-I.- 00 1�27 9
JOBSITE ADDRESS 6g pmd e .t OWNERS NAME
G B c�
OWNER ADDRESS 66/Mid sY- t4 Yi ''lto TEL 301 r lO8-//30 FAX
TYPE OCCUPANCY TYPE COMMERCIAL G
� �� ❑ EDUCATIONAL ❑ RESIDENTIAL II
CLEARLY
NEW:❑ RENOVATION:ik REPLACEMENT: ❑ PLANS SUBMITTED: YES
❑ NO-fi]
APPLIANCES 1 FLOORS-4 B`M 1 ? 3 4 5 6 7 f 9 10 11 12 13 14
BOILER
BOOSTER __I___ -�
CONVERSION BURNER __I
COOK STOVE J
DIRECT VENT HEATER
DRYERI
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
•
MAKEUP AIR UNIT
OVEN .
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
V UNVENTED ROOM HEATER
WATER HEA1 HEATER
1
OTHER
1
f .
`' INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES kf NO ❑•
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V 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 valves this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT 0
`� 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 compliance with ail Pertinent provision of the
Ott.
Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
JO
PLUMBER GASFITTER NAME 05E"S' f-� f' i
6 '" LICENSE#���.??. / SIGNATURE
MP yj MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION ❑#i PARTNERSHIP❑#r LLC t#I:
COMPANY NAME
DDRESS 36/ t.cK_Zsi d ktt
CITY 1122- - y fi'12iat CrLC STATE ZIP m2' 3
TEL ?SG ,25- //28.0._
FAX CELL W C �( t z?Z- EMAI L
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