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HomeMy WebLinkAboutBLDG-23-000247 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' CITY IYARMOUTH MA DATE (July 14,2022 I PERMIT# BLDG-23-000247 JOBSITE ADDRESS 129 KATHARYN MICHAEL RD UNIT4 OWNER'S NAME (Margaret Carvalho G OWNER ADDRESS 129 KATHARYN MICHAEL ROAD YARMOUTH PORT MA 02675 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL CLEARLY NEW: ❑ RENOVATION:❑ 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/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 'Brian Clark I LICENSE# 113164 I SIGNATURE MP© MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0#I I PARTNERSHIP ❑# LLC ❑#I COMPANY NAME: 'BRIAN K CLARK I ADDRESS. (PO BOX 2288, CITY IORLEANS I STATE MA ZIP 1026536288 I TEL I FAX I CELL I I EMAIL Icbplumbing13Acimail.com 7i HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORIB 4r ,306 ...... CITy_ l 0 L OS; MA DATE ? 0"1-- 2 PERMIT# Z -- cZy? 3U S E,4ID'ESS �r`r►0,-e> OWNER'S NAM r• 1 B LING 'FUtatk'MISR: SS By TEL FAX PRINTOCCUPANCY—YFE COMMERCIAL r CLEARLY ❑ EDU„A'i IGPJAL 0 RESIDENTIAL NEW: RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 APPLIANCES�. FLOORS-4 BEM 1 BOILER ®®�®®® J t BOOSTER ....„, CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER lai -- FIREPLACE m — FP,YCiLATOR r - FURNACE � GENERATOR —�----_ GRILLE .1.1__ INFRARED HEATER �� LABORATORY COCKS 5=�____1 MAKEUP AIR UNIT __ OVENNMI POOL HEATER ��=_� ; ROOM!SPACE HEATER • _� ROOF TOP UNIT MinTEST _ MaiMni UNIT HEATER ® • �_�� .M. UNVENTED ROOM HEATER M WATER HEATER -—_ OTHER1111111imumminimm11111111111111111.1111111111111.=NMCNN_ _______ Min I have a current liabili insurance INSURANCE COVERAGE -�� policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 11:3---- - • OTHER TYPE INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by 142 of the Chapter Massachusetts General Laws,and that my signature on this permit application waives this requirement. . P .i ''\ SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 '`4-• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and `� and that all plumbingwork p � and installations performed under the permit issued for this application will be in corn lia ce with all Pero Massachusetts State Plumbing Code and Chapter 142 of the accurate to the best of my I;nowl e L`! General Laws. GL' pr not PLUMBS GASFITTER NAME LICENSE#I.31 6 SIGNATURE q SI MP , MGF 0 JP ID JGF 0 LPGI 0 C RE CORPORATION El II PARTNERSHIP[]��COMPANY NAME c-b lb i n LLC h ADDRESS C X 'z a g CITY fir) STATE ZIP U�b J- FAY. CELL TEL EMAIL �� (1 b >h 13 - A. h'ILi d 0