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HomeMy WebLinkAboutBLDG-23-001845 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -401-_ CITY YARMOUTH MA DATE October 06,2022 PERMIT# BLDG-23-001845 1 I JOBSITE ADDRESS 15 JEFFERSON AVE OWNER'S NAME OLSON JOHNATHAN E G OWNER ADDRESS LARRIMORE KIMBERLY 15 JEFFERSON AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ 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 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 John Kane LICENSE# 22755 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JOHN KANE ADDRESS. 39 MONOMOY RD, CITY S YARMOUTH STATE MA ZIP 026641984 TEL FAX CELL EMAIL Ikanee45(a,vahoo.com F A At.:HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 3-6 ._a . CI W c a l�a ill in MA DATE l0%i j a a PEp rr t Z - l�r`f f r 0 ;�DP.ESs /S Tc ff-evso /4 v- OWNERS NAME Jail eld Ifo'i OWNER AQDP,ESS: t;a vh e " F 3UILDI DEP RTMENT L'y -ATE OR-- IIPAlifY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL l[ PRThrf CLEARLY ► N:0 RENOVATION:B REPLACEIvRENT:❑ PLANS SUBMI i 1 tt): YES❑ NO} I APPLIANCES-1 FLOOR-4 I Bsnt 11 I . 13 14 I s + o I 7 f 8 I 9 I 10 11 ( 12 13 I 14 I BOILS I I I I I BoasTER I I I I I I I CONVERSION BURNER COOK STOVE I / DIRECT VER T HEA T ER I I DRYER FIREPLACE I I I FRYOLATOR I I I I FU RNACE ___I ( I GENERATOR ' I GRIt1F I INFRARED HEAL tK I ` I LABORATORY COCK I MAKEUP AIR UNIT I I I OVEN I POOL HEATER ROOM 1 SPACE HEATER I I I i ROOF TOP UNIT I TEST_ I I I-` I_ I UNIT HEA:i di I I I I_ I 1 UNVENTED ROOM HEATER i I I WATER HEATER I I _ I I F I I I I INSURANCE COVERAGE I have a current liability insurance policy or is substantial equivalent which meets the requirements of MGL Ch.142 YES fij NO 0 If you have checked YES please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 5a OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE lfi►ANER: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 CHECK ONE ONLY: OWNE2 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 Massachuse1 s State Plumbing Code and Chapter 142 of the General Laws. �/�.r. PLUMBERIGASFI I tkNAME: 7a�, KO r i .uc�SE� aa 7s s SIGNATURE COMPANY NAME i q h i. j<'G r7 j-v g c 4- 10 5 ADDRESS: 3 G el o n it v l o y fir/ " CITY: S-'(U,r nr1 OU In STATE YYI c 21P: 6 6 q FAX: I EL CELL: TO $ -9$S-3-eS b MAIL MASTER 0 JOURNEYMAN r0 LP INSTALLER❑ CORPORATION 0- PARTNERSHIP n= r W