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HomeMy WebLinkAboutBLDG-22-005115 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,' 3 CITY !YARMOUTH MA DATE IMarch 15,2022 PERMIT# BLDG-22-005115 a JOBSITE ADDRESS 11 SEASIDE VILLAGE RD OWNERS NAME IMELARAGNI DAVID C G OWNER ADDRESS 2 DIANA DR WOBURN MA 01801 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 - PLANS SUBMITTED:YES ❑ NO 0 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 1 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 0 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 ILESTER WADE I LICENSE# 14569 I SIGNATURE MP❑ MGF © JP❑ JGF❑ LPGI 0 CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#I I COMPANY NAME: ILESTER J WADE I ADDRESS. 122 CAPTAIN ISIAHS RD, I CITY ICOTUIT 'STATE IMA I ZIP 1026352702 I TEL I I FAX 1 'CELL 1 I EMAIL 1 I - • • UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' r u•4-h MA DATE •--)4-' ." PERMIT# 2�- S-II� i ' _____ Z MITE I s s k`d e \ o L c-i e. ", OWNER'S NAME tau,of /U-c, et re{9 n, g ILDI�G DEPAF2TM N S+tl. ti.bOVC TEL7fj1-q 3 - 1 t J SAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL It PUNT CLEARLY .NEW.fig RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO APPLIANCES I FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 I 11 i2 13 14 BOILER BOOSTER ' • CONVERSION BURNER , COOK STOVE DRECT VENT HEATER DRYER • • FIREPLACE FRYOLATOR FURNACE . GENERATOR GRILLE • . INFRARED HEATER LABORATORY COCKS I MAKEUP AIR UNIT OVEN ' POOL HEATER . ROOM!SPACE HEATER • _ ROOF TOP UNIT TEST • UNIT HEATER • UNVENTED ROOM HEATER WATER HEATER _ • OTHER • - INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ® NO 0 I F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0 OWNERS INSURANCE WAIVER:I am aware that the licensee does not layette insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application wglygs this requirement. • CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT t hereby certify thetatl of the debits and information I have submitted or entered regarding this application are true and accurate to the best of knowledge • and that all plumbing work and installations performed under the permit issued for this application will be in compliance all P of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. x PLUMBER-GASFITTER NAME LLs+•e.v- (Oa cte. LICENSE# 4 5t0 R RE • MP 0 MGF® JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME "^Y t.Cod Tsndo. so cQ -i4 eta:-c..( ADDRESS a•3 Sow tut't pi got. CITY Met sin.9f..' STATE MA ZIP 0,?-(o 49 TEL 50 V-41 i--i$$1 FAX /J,A CELL 50%-150-lieva EMAIL il1-aC cc.ip3civee,a-Fois, co•v.%