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HomeMy WebLinkAboutBLDG-23-001359 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY IYARMOUTH MA DATE September 14,202 PERMIT# BLDG-23-001359 kg, Iff JOBSITE ADDRESS 129 KATHARYN MICHAEL RD UNIT4 OWNER'S NAME 'Margaret Carvalho G OWNER ADDRESS 29 KATHARYN MICHAEL ROAD YARMOUTH PORT MA 02675 TEL' TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 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 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 El BOND 0 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 LICENSE# 113164 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑#I PARTNERSHIP ❑# LLC ❑# COMPANY NAME: 'BRIAN K CLARK ADDRESS. 'PO BOX 2288, CITY IORLEANS STATE MA ZIP 1026536288 TEL ' FAX CELL EMAIL 'cbplumbing13Agmail.com MAS.SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING 1 Ftig* 1 WORK p `• MA DATE PERMIT# 23 - / 3 5-9 I S P 1 4 2> SIT AC DRESS 2-9 Ka+Lar l icka / OWNER'S NAM L TEL FAX ,G DE ;RNA ND5RESS sy .r. !., ' TYPE COMaERC AL❑ EDUCATIONAL ❑ RESIDENTIAL( ' P}NT CLEARLY NEW:❑ RENOVATION: I'J REPLACEMEN T: ❑ PLANS SUBMITTED: YES❑ NO 0 APPLIANCES j FLOORS—F sCM t 2 BOILER iinomai9 10 11 12 €3 14 BOOSTER CONVERSION BURNER COOK STOVE111— DIRECT VENT HEATER -=-- - DRYER -_ FIREPLACE ____ FRYOLATOR _ FURNACE - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - POOL HEATER ROOM I SPACE HEATER MENEM ROOF TOP UNIT . 7. TEST UNIT HEATER �w UNVENTED ROOM HEATER �_ WATER HEATERMIMI IIMM DTHER iliallIMMN= � INSURANCE COVERAGE I have a current liab€li insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES rj NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE ❑ i�Y CEiFCI�CIhIG THE APPRC7PRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHE R TYPE INDEMNITY 0 BOND 0 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. C. •, SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ `l:• 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 prov' I, of Massachusetts State Plumbing Code and Chapter 142 f th Generalof my I:now�"ge p Laws. �y PLUMBER GASFITTER NAME �4�vV4 e�a . LICENSE#f ��� MP . MGF❑ JP 0 JGF LPGI SIGNATURE ❑ ❑ CORPORATION ❑# PARTNERSHIP❑11 LLC #1 COMPANY NAME V in $. gt�, h ADDRESS ❑ �p �x "Z�Z.�� CITY a STATE Yr/A ZIP�' $'" FAX TEL cSZ��� G���.3Q" CELL EMAILLe-k FU�'lIIItIi