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HomeMy WebLinkAboutBLDG-23-003434 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f i1= CITY YARMOUTH MA DATE December 20,202; PERMIT# BLDG 23 003434 JOBSITE ADDRESS 17 BRUSH HILL RD I OWNER'S NAME GARCIA MICHAEL R G OWNER ADDRESS CORBEAU DIANNE 7 BRUSH HILL RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: El 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 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# 115219 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: IJARED WILBER I ADDRESS. 1474 WINSLOW GRAY RD, CITY IS YARMOUTH I STATE IMA I ZIP 1026644317 I TEL I FAX I I CELL I I EMAIL Iiarbernie123ia7gmail.com ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING ,.J s WORK r ' '';'. CITY i D.1t'tA�1� D ' 11 PERMIT* 2.3- 3`7 3 ' ili MA DATE 1 a. JOBSITE ADDRESS 7 f j(Iti4 Y1 14 it( 49OWNER'S NAME ^ - t6,.. G OWNER ADDRESS Sri hie TYPE OR TEL FAX PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL[�'- NEW:Q' RENO\/ATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES J. FLOORS BSM t BOILER 5 6 7 9 10 I.l 13 14 BOOSTER I I a in CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER - FIR DRYER IMI FIREPLACE FRYOLATORall FURNACE _—_ - GRINERATOR _ GRILLE ____--------1 • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ` _�� in OVEN �11i[ POOL HEATER um MEN Ili ROOLHEATEE HEATER ROOF TOP UNIT ��.� �- TESTNM NM UNIT HEATER ... . in I L DiN��n UNVENTED ROOM HEATER 'S - -_ all WATER HEATER OTHER EN 1111111 _ Mil IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIEIINNNINNI IIIII alIIII INSUGE I have a current liabili insurance policy or its substantial equivalent which NCE DVme is the requirements of NIGL.Ch.142 YES ❑ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [} --- OTHER TYPE INDEMNITY ❑ BOND fOWNER'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 CHECK ONE ONLY: OWNER ❑ AGENT ❑ 7: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 `� and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent LE j �` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. of my knowledge provision of the PLUMBER-GASFITTER NAME J axed V a I e-Y LICENSE# t 5). p SIGNAT RE MP I7Q MuF❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION # PARTNERSHIP❑# LLC COMPANY NAME �( 9 ❑ u I� ADDRESS CITY _ Jja r ln/t 6 _ FAFAX �� STATE_j�� ZIP_L�— TEL. 7 9L/ CELL_ S /r! EMAIL a Ae YI 1 - i . / i 6 /