Loading...
HomeMy WebLinkAboutBLDG-23-003449 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 21,202; PERMIT# BLDG-23-003449 JOBSITE ADDRESS 30 BUCKWOOD DR OWNER'S NAME O'DONNELL JAMES M G OWNER ADDRESS 30 BUCKWOOD DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 0 NO El 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# 15219 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JARED WILBER ADDRESS. 474 WINSLOW GRAY RD, CITY S YARMOUTH STATE MA ZIP 026644317 TEL FAX I CELL I EMAIL iarbernie123(a omail.com •' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING ms I- WORK ` 6N CITY lCLY d �� —Z'Z E z3 - 3�i'I � .'; MA DATE /2 `" PERMIT JOBSITE ADDRESS O CY tvoGc ( 0(� OWNERS NAME Jjj.Q j� OWNER ADDRESS jaJ/a� I TYPEO� TEL FAX PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY NEW: RESIDENTIAL tJE'W:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 FLOORS-+ BSM 1 ? 3 q 5 6 7 u BOILER 9 10 I i 12 I3 14 BOOSTER CONVERSION BURNER I I COOK STOVE DIRECT VENT HEATER DRYER _J FIREPLACE FRYOLATOR _� , FURNACE _____I GENERATOR GRILLE ' INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ' • OVEN POOL HEATERI j ROOM/SPACE HEATER ---�-- ROOF TOP UNIT TEST UNIT HEATER I INVENTED ROOM HEATER WATER HEATER ---- OTHER —-T- — INSURANCE COVERAGE I I have a current liabill insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES N© 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. .t SIGNATURE OF OWNER OR AGENT CHECKONE ONLY: OWNER ❑ AGENT 0 '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 ` and that all plumbing work and installations performed under the permit issued for this application will be in compliance ith a I Pertinent rovi ' �• Massachusetts State Plumbing Code and Chapter 142 of the General Laws. knowledge Q? sion of the PLUMBER GASFIT I ER NAME G�Ve 1 � � ` ,� � LICENSE# SIGNATURE MP I MGF❑ JP ❑ JGF❑ LPG] ❑ CORPORATION fi PARTNERSHIP❑# LLC 0 COMPANY NAME J aV'e d 14`,Y1 .1 j� � CITY � �--- ADDRESS� f if �/I hs !1 W �g U STATE D ZIP (> 2 G Ll TEL 7�`y FAX CELL_4(h%�-� EMAIL Itiz-k t C trO r °tom 1 Z 3 t� �Z (>Vj� y Gi'I