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HomeMy WebLinkAboutBLDG-23-004625 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK  '‘4,,,� � CITY 'YARMOUTH MA DATE February 21,2023 PERMIT# BLDG-23-004625 JOBSITE ADDRESS 111 SPARROW WAY OWNER'S NAME 'Rita Andrade G OWNER ADDRESS 11 SPARROW WAY SOUTH YARMOUTH MA 02664 TEL' TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 I 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 'LICENSE# 132655 I SIGNATURE MP 0 MGF ❑ JP© JGF 0 LPGI 0 CORPORATION 0#I I PARTNERSHIP ❑#I ILLC 0#' I COMPANY NAME: 'ANSON CELIN I ADDRESS. 126 Capt.Blount Rd, I CITY 'South Yarmouth I STATE IMA I ZIP 102664 I TEL ' I FAX I I CELL ' I EMAIL 'ansoncelin aAvahoo.com I 4. f—U MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `t�" c." CITY U� 4Gi'�Z Cs MA DATE 2- Z/-VI "Z-3- -� PERMIT* �l071► JOBSITE ADDRESS oI I SOCArr40.0 PO Gill OWNER'S NAME__A:4___ /an dcu dk GOWNER ADDRESS 115Airrdt1S ii3Oc. y TEL FAY, TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-+ 8 M 1 ? 3 4 5 6 s 10 11 12 I--�BOILER i BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER DRYER ______I FIREPLACE i FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER r— LAL3C)PJiTOR`f COCKS I ; MAKEUP AIR UNIT • OVEN POOL HEATER i ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I OTHER __ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES , NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 siOnature on this permit application waives this requirement. i. SIGNATURE OF OWNER OP,AGENTCHECK ONE ONLY: OWNER ❑ AGENT ❑ %z 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 - vand that all plumbing work and installations performed under the permit issued for this application will be in comp115nce with all Perti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / - PLUMBER-GASFITTER NAME '' __. LICENSE# L&SS SIGNATURE MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP[❑# LLC❑ft COMPANY NAME Ce i'- P1 w F� i ;r2 ADDRESS P,ES, Z C Win"n (c��� Rib CITY �'ti Gttn74 STATE d47 4 ZIP G L-GcII TEL—SC�1f-Z -c..7 - FAX CELL EMAIL_ as ct-iC NC.n K/zezo