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HomeMy WebLinkAboutBLDG-23-003037 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' ' CITY YARMOUTH MA DATE December 05,202; PERMIT# BLDG-23-003037 JOBSITE ADDRESS 129 GREENLAND CIR OWNER'S NAME Joshua Kelley G OWNER ADDRESS 29 GREENLAND CIR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 111 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 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 1 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 (Michael Saurette LICENSE# 134174 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG' El CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ISAURETTE BROTHERS I ADDRESS. 17 Barnhouse Road,7 Barnhouse Road CITY IDennisport STATE Ma. ZIP 02639 TEL FAX CELL EMAIL Irsox555ta7gmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -- f ' Y ()bit Nw3O ���� CITY u� MA DATE # 2`�— 3p 11 CI' PERMIT JOBSITE ADDRESS I 6-reef la nd c_- OWNERS NAME --5-0S of l GOWNER ADDRESS TEL 7 7 3653CR 6 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL RESIDENTIAL CLEARLY NEW:❑ RENOVATION:] REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-4 6SM 1 BOILER 2 3 4 5 6 7J ° 9 I 10 11 12 13 1 BOOSTER l C CONVERSION BURNER COOK STOVE DIRECT VENT HEATER ` DRYER __, FIREPLACE FRYOLATOR I FURNACE X --I GENERATOR GRILLE __) INFRARED HEATER i LABORATORY COCKS __________I MAKEUP AIR UNIT I OVENR E C-E -D --I POOL HEATER ---i ROOM I SPACE HEATER ' 1 3(�1L. 2 , ROOF TOP UNIT TEST UNIT HEATER • UNVENTED ROOM HEATER WATER HEATER x I OTHER I 1 INSUERAGE I have a current lialJIi insurance policy or its substantial equivalent which nw h cNCE Ohvmeets the requirements of MGL.Ch.142 YES I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW• d 0 LIABILITY INSURANCE POLICY El 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 AGENT CHECKONE ONLY: OWNER ❑ AGENT El `-�` 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 and that all plumbing work and installations performed under the permit issued for this application will be in compliant w' al Pe ' LE j Massachusetts State Plumbing Code and Chapter.142 of the General Laws. knowledge p vision of the PLUMBER-GASFIT'fER NAME LICENSE#34 174_ SIGNATURE MP❑ MGF❑ JP JGF❑ LPG' ❑ CORPORATION❑# IV�E- COMPANY NAME �2V T3>rn�-{„P� PA."RTRSHIP❑�� LLC❑ ADDRESS 7 f3�t�n r CITY n_�>° j5 ___ STATE p ZIP�V3q TEL FAX CELL 77 SAX ��JO�O EMAIL L 55 140, rdi t COM C 6i1D9