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HomeMy WebLinkAboutBLDG-22-001333 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK E' CITY 'YARMOUTH MA DATE (September 08,202 PERMIT# BLDG-22-001333 JOBSITE ADDRESS 125 CAMP ST OWNER'S NAME (Ahmed Shahin G OWNER ADDRESS 25 CAMP ST WEST YARMOUTH MA 02673 TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT PLANS SUBMITTED:YES El NO El NEW: ElRENOVATION:❑ REPLACEMENT:El FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER _CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 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❑ 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 (Peter Riva I LICENSE# 113447 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#I 19 BAYVIEW ST, COMPANY NAME: (Peter E Riva ADDRESS. I CITY IMARSHFIELD I STATE IMA I ZIP 1020502906 I TEL I FAX 1 I CELL I I EMAIL I .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ® I CITY �'�'14 `"f MA DATE ` li /Z/ PERMIT# 22— I"S 33 lii' ":;� 0 JOBSITE ADDRESS 254444V $ OWNER'S NAMEJ4t Sh 'r' LPL Q I TELA"'141S—i;5- "( FAX !'04. m : ;,, i OWNER ADDRESS ST 2 . 0 i '.'PII,C3Rf OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL, r iif A � PLANS SUBMITTED: YES 0 NO❑ ce L _ 5 NEW:- ' RENOVATION:❑ REPLACEMENT:❑ mm •PPLIANCEC 1- FLOORS-4 SSlu1 1 2 3 4 5 6 7 8 9 10 11 12 13 I 1" BOILER d BOOSTER CONVERSION BURNER, 1 COOK STOVE I DIRECT VENT HEATER DRYER, ! FIREPLACE — 1 FRYOLATOR FURNACE — GENERATOR GRILLE I INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN l-- POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST ... .._..... .._ --- UNIT HEATER • UNVENTED ROOM HEATER WATER HEATER - OTHER ! , ____±±_±I_ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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 signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 3 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 a curate to the best of my knowledge "- and that all plumbing work and installations performed under the permit issued for this application will be in compli c ith all P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i r 'L-L,6 Vk`I SIGNATUR PLUMBER-GASFITTER NAME Pe re r t�.t v�. LICENSE L___ PARTNERSHIP❑# LLC-R yt MP MOF CI ❑ JGF CI LPGI CI CORPORATION❑0 _ !l ADDRESS [ gait 's COMPANY NAM �w [ . CITY 4 , - STATE ZIP TEL FAY. • �Ii c CELL EMAIL r