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HomeMy WebLinkAboutBLDG-23-002442 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 03,202; PERMIT# BLDG-23-002442 JOBSITE ADDRESS 7 DUNSTER PATH OWNER'S NAME LOUGHLIN KAREN B G OWNER ADDRESS HALDE NANCY A 7 DUNSTER PATH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El PRINT 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 1 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 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 Gregory Selfe LICENSE# 26714 SIGNATURE MP❑ MGF 0 JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: GREGORY A SELFE ADDRESS. 41 SPRINGER LN,41 SPRINGER LN CITY WEST YARMOUTH STATE MA ZIP 026734930 TEL FAX CELL EMAIL selfeprepat7.vahoo.com 1 �1;�= N.'' f AssAoHLISETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING -J -�s h rh CITY �1�RtMo� WORK MA DATE l!-;— " - 3-?.a-- PERMIT# z-3 Ltih 2 JOBSITE ADDRESS � D" '4e< Ppfl, �� n OWNERS NAME G OWNER ADDRESS 7 Du n S lei (A-l1 To•Q8)rrr- Y06#4-- FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY RESIDENTIAL NEW:❑ RENOVATION:`} ( REPLACEMENT:52 PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 4 FLOORS-4 SSM 1 BOILER 5 6 7 ° 9 10 I'I 12 13 1 BOOSTER I ---- I 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 INSURANCE I have a current liabili insurance policy or its substantial equivalent COVERAGE ent which s the requirements of IIIIGL.Ch.142 YES I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �Nd LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND • OWNER'S INSURANCE WAIVER: El 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 OP,AGENT CHECK ONE ONLY: OWNER ❑ 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 P ' ent provision of the Massachusetts State Plumbing Code and Chapter'142 of the General Laws. g PLUMBER-GASFITTER NAME G o TO , JKE LICENSE#a6 7 1 y ION URE MP ❑ MGF❑ JP Ea JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑it- LLC❑4: COMPANY NAME// '-{I SPIe f n bf G � ADDRESS CITY W YA at ft-11, STATE ltiA ZIP 0ee73 TEL_CsoI) >'�e, /y1y FAX CELLS �7 r<e �• y EMAIL Sc f FC tt"3 e ys-I► .4 Ors,