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HomeMy WebLinkAboutBLDG-22-007206 - t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,, CITY YARMOUTH MA DATE June 14,2022 PERMIT# BLDG-22-007206 JOBSITE ADDRESS 50 BRAY FARM RD SOUTH OWNER'S NAME SCHINKOWITCH CASEY T G OWNER ADDRESS SCHINKOWITCH AARON M 69 RIVERSIDE DR NORWELL MA 02061 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 1 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 INhan Nguyen I LICENSE# 115210 I SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! ❑ CORPORATION 0#I PARTNERSHIP ❑# LLC ❑# COMPANY NAME: INHAN H NGUYEN ADDRESS. 1284 Bridge St, CITY IRaynham STATE MA ZIP 027671975 TEL I FAX I I CELL I I EMAIL hightek2010avahoo.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERM! TO PERFORM GAS FITTING WORK YA- �(�is ���`�.� �� CITY � • ����;�.: MA DATE 6 9 r d- PERMIT* 'VI �j__ JOBSITE ADDRESS So Br Q,rry1 k �'"'`-a'E1WNER'S NAME I�I'C OWNER ADDRESS TELG �254�'�CT() TYPE OR AY, PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL I./i NEW:p RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-4 SSM 1 _, BOILER I 3 4 5 6 7 ° 9 11 I'i t2 13 t,, BOOSTER —`---� CONVERSION BURNER COOK STOVE - ___ DIRECT VENT HEATER _ DRYER j-- FIREPLACE L—� FRYOLATOR FURNACE I ___________I GENERATOR GRILLE __J INFRARED HEATER I III LABORATORY COCKS MAKEUP AIR UNIT :--_, ._..� -� OVEN POOL HEATERkit U I yi ROOM I SPACE HEATER { ski ROOF TOP UNIT ILDIhG p TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I �________1 OTHER i 1 - INSUNCE COVERAGE I have a current liabill insurance policy or its substantial equvaallent 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 NO ❑ LIABILITY INSURANCE POLICY S2 OTHER TYPE INDEMNITY ❑ BOND • • OWNER'S INSURANCE WAIVER: ❑ I 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 CHECK ONE ONLY: OWNER ❑ AGENT 0 ` : 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 myk `- 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. knowledge LE PLUMBER-GASFITTER NAME OH Ac.13 `/ LICENSE# 15 2-L SIGNAT E MP r MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION ORPC)RATION❑# PARTNERSHIP 0# LLC COMPANY NAME f'f i 1''1�t ,12 N �g ❑ ADDRESS �- 6 r - i�l G S'j.-- CITY n STATE A- ZIP 6 Z 6 FAX TEL I gZ R3 g�Z� CELL EMAIL i . . _ j