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HomeMy WebLinkAboutBLDG-23-003187 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c� CITY YARMOUTH MA DATE December 08,202: PERMIT# BLDG-23-003187 JOBSITE ADDRESS 85 WIANNO RD OWNER'S NAME RING RONALD J G OWNER ADDRESS RING ERNESTINE J 85 WIANNO RD YARMOUTH PORT MA 02675 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 Darrell Shedd LICENSE# 8403 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DARRELL D SHEDD ADDRESS. 730 TYLER ST, CITY PITTSFIELD - STATE MA ZIP 012014319 TEL FAX CELL EMAIL dshedd 5 sheddplumbina.com _AN` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK u v�1 ,g: CITY: VAR MO U T H- MA. DATE: 1-Z/./ 2 2— PERMIT#Z 3- 3/ 2-) JOBSITE ADDRESS': i 4 Ni tJo /. G Q�5 ,/��.b OWNER'S NAIL. ►,(�rf c(Ott OWNER ADDRESS: CJ5 LUI/A IJ IJ 0 R.D TEL: FAX: PRINT TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATioNAL 0 RES iTIAL V ;- CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ 1APPLIANCES1 FLOOR-, Qsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ CONVERSION BURNER In COOK STOVE I . DI CT VENT HEATER DRYER - FIREPLACE FRYOLATOR FURNACE GENERATOR ,, GRILLE INFRARED HEATER Via LABORATORY COCK MAKEUP AIR UNIT 4.4 �:7 Y EN m - 4 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST Z UNIT HEATER - Li j UNVENTED ROOM HEATER WATER HEATER - Y I have a current Crabit insurance INSURANCE COVERAGE r bypolicy or its substantlal equivalent which meets the requkernents of MGL.Cit.142 YES iki NO 0 If you have checked DI,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY RI OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER;lam aware that the licensee does not have the insurance coverage required by Ctmpter 142 of the Massachusetts General Laws,and that my signature on this permit applicationwaives this requirement SIGNATURE OF OWNER ORAGENT CHECK ONE ONLY: OWNER 0 AGENT 0 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 a In corn with all Pertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 oft*General Laws. ' PLUMBER/GASFITTERNAME 04k_tg6 t L 5i-160i) LICENSE# 3216 SIG RE COMPANY NAME: .540-Di Pt_ti 8i tv‘ ADDRESS: 4 �1E-049t�r til it y' CITY: / 7-1-MO STATE: MA MR 6 z_4, 5-2__ FAX: TEL CELL: 7/-3—144r'-11/O f EMAIL: d k Fddl -.Si(F/4' )(i ebfAH , r pv MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION 0# PARTNERSHIP 0# LLC 0#