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HomeMy WebLinkAboutBLDG-23-003063 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY YARMOUTH BLDG-23-003063 MA DATE December 05,202, PERMIT# JOBSITE ADDRESS 11105&1107 GREAT ISLAND RD I OWNER'S NAME CHACE MALCOLM G JR TR(EST OF) G OWNER ADDRESS C/O POINT GAMMON 46 ABORN ST 4TH FLR PROVIDENCE RI 02903 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 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 ❑ 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 (Franklin Kelley LICENSE# 112330 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPG' El CORPORATION❑#I PARTNERSHIP ❑# LLC ❑# COMPANY NAME: IFRANKLIN W KELLEY ADDRESS. 124 FREDERICKSBURG AVE, CITY IHARWICH I STATE MA ZIP 026452134 TEL I FAX I CELL I I EMAIL IfwIw comcast.net MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY e``� C�JM� L>�� _ ' ,'-. MA DATE t a- -a--)--- PERMIT 2� 3 os JOBSITE ADDRESS 1 l 0 ' 6 Y4f--1+.301 LcA R, OWNERS NAM I4A C Vt 4 c GOWNER ADDRESS TEL FAX • TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUr EDUCATIONAL IOdAL ❑ RESIDENTIAL��PRNi CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: [ _ PLANS SUBMITTED: YES❑ Id0❑ I APPLIANCES-1 FLOORS-+ BM t , ; BOILER f 2 3 1 5 6 ? 8 l 9 10 L 11 12 13 ch i BOOSTER �7 CONVERSION BURNER 1-- I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE —�� FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER I LABORATORY COCKS I 17-17--- 1 MAKEUP AIR UNIT I ; OVEN --I POOL HEATER R E C E I V E D -- ROOM/SPACE HEATER ROOF TOP UNIT 55 2022 ' TEST . ... . .. UNIT HEATER BUILLL G D��ylrzl-MEW ,_.- LJNVENTED ROOM HEATER a, __ — iNATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [j� 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. • SIGNATURE OF OWNER OR AGENTCHECK 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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �pm(31i�nce all P i n r 'sion of the b PLUMBER-GA ' ITTER NAME LICENSE la 336 SIGNATURE MP MGF❑ JP ❑ JGF❑ LPG' ID ❑# PARTNERSHIP❑# LLC❑ COMPANY NAME - Vc k le. P L, ,(� ADDRESS fD' 4. ( nc-c>2,^ P� , CITY �(�E'�`' �i S STAT 4' ZIP G F6, '7 TEL TEL CELL'JU` -6cf$'^Llzf4.15 MAIL LU L C.C� FAX out.) ti095( iS