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HomeMy WebLinkAboutBLDG-23-003056 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK L -7. CITY YARMOUTH MA DATE December 05,202; PERMIT# BLDG-23-003056 L, JOBSITE ADDRESS 1310 SOUTH SHORE DR OWNER'S NAME 'SAFFORD HOWARD I G OWNER ADDRESS SAFFORD MARY JO 92 JUNIPER RIDGE DR FEEDING HILLS MA 01030-1541 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ED PRINT CLEARLY NEW: m 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 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 1 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 El 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 Jared Wilber LICENSE# 15219 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! ❑ CORPORATION❑#I I PARTNERSHIP ❑# LLC ❑# COMPANY NAME: IJARED WILBER I ADDRESS. 1474 WINSLOW GRAY RD, CITY IS YARMOUTH I STATE (MA I ZIP 1026644317 I TEL I FAX 1 I CELL 1 I EMAIL Ilarbernie123(a gmail.com - --:, �4. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ram ti,.. : � CITY ��C\le h'r L t-1,+Ii MA DATE 1.z '' `� 2i 2 3 - -=; PERMIT 3 o S-� JOESITE ADDRESS 31 a .cam ti- t� cl1a(' - i.OWNER'S NAME J tr Ec r, GOWNER ADDRESS 5 4 471 =- TEL FAY, TYPE OR OCCUPANCY TYPE COMMERCIAL E PRINT ❑ EDUCATIONAL ❑ RESIDENTIAL�J. CLEARLY NEW:[ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ I APPLIANCES 1 FLOORS-4 BSlul 1 3 q 5 6 o BOILER 9 to 11 12 lam_ BOOSTER CONVERSION BURNER ---J COOK STOVE DIRECT VENT HEATER DRYER _I 1 FIREPLACE FRYOLATOR j FURNACE ._____I GENERATOR 1 _______I GRILLE INFRARED HEATER LABORATORY COCKS _________I - MAKEUP AIR UNIT R E • OVEN �.,.___ ._�- • C AS �_i POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT RTMENT , TEST ... Buy — uv _�— rr UNIT HEATER - - INVENTED ROOM HEATER _r I WATER HEATER OTHER INSURANCE lent hic I have a current liabili insurance policy or its substantial equ va w COVERAGE meets he reuirements of MGL Ch142 . . YES rl q �f�0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I 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 I • Massachusetts General Laws,and that my signature on this permit application Wily es this requirement. • AGENT SIGNATURE OF OWNER.OR, CHECK ONE ONLY: OWNER ❑ AGENT El I:., 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 compliant with II Pertinent o�ision of time �` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. g `� �r. PLUMBER-GASFIT'fER NAME LICENSE# >.�a.f SIGNATURE ;��,i MP (' 9, MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION ar PARTNERSHIP❑# LLC❑# COMPANY NAME I/i,r ,l r 1 � �JL i K ADDRESS 4 _.k�'�� �L �l h l la LT7-v O�im w , c 4 CITY . STATE ZIP (j 2 Ll 6 q TE FAX I-_2g_k 'J�i�23ti CELL_ y� y� EMAIL_�y- V MI P 2