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HomeMy WebLinkAboutBLDG-23-002465 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 04,202; PERMIT# BLDG-23-002465 JOBSITE ADDRESS 18 HIALEAH AVE OWNER'S NAME BROWN WILLIAM J G OWNER ADDRESS BROWN JEANNE M 18 HIALEAH AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW: ❑ 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 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 ❑ 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 Francois Paravisini LICENSE# 15211 SIGNATURE MP 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: FRANCOIS PARAVISINI ADDRESS. PO Box 2585, CITY Orleans STATE MA ZIP 026536585 TEL FAX CELL EMAIL baysideaanthecapecodplumbers.com MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK crry Wesr tp4Rmou744 MA DATE 11101)11- PERMIT# 2-3— 2 Li b5 ...,—, JOBSITE ADDRESS I 7. H•iA LE 014 L A iv,E OWNER'S NAME 15—eD I/0 4 G OWNER ADDRESS TEL 508-21a0• 073' FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL gia PRINT CLEARLY NEV:0 RENOVATION:0 REPLACEMENT:gi PLANS SUBMITTED: YES 0 NO 2 APPLIANCES'I FLOORS-0 9$61 1 2 3 4 5 5 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 uNri _ POOL HEATER ROOM I SPACE HEATER ' „ _ . . . . ROOF TOP UNIT TEST UNIT HEATER iThIVENTF_D ROOM HEATER " WATER HEATER OTHER . . . , INSURANCE COVERAGE , - I have a current Mg&insurance policy or Its substantial equivalent which meets the requirements of PG3L 111.142 YES ati NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX MOW UABIUTY INSURANCE POLICY'Ef-- arm TYPE mown, 0 BOND 1:3 OWES 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**Mon mks this requirement. CHECK ONE ONLY: OMER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that elf the dotage end informatkm I have submIttecior entered regardfrtg this appliceftwe true and accurate to the best of my knowledge and that aft pkInbing work and Installations performd under the permit Issued for this application will ben' with all Pertinent - Masenhusette ante Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE415211 SIGNATURE • MP 0 MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION g)#205872589 PARTNERSHIP 0# LLC 0# COMPANY NAME Bayside Plumbing& Heating ADDRESS P.O. Box 2585 sCITY Orleans STATE MA . ZIP 02653 Ta 508-255-4555 FAx 774-316-4249 CELL 774-216-9484 EMAIL BaysideeTheCapeCodPiumber&com CSC- 223c'' ///if22.- 15-0.4)