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HomeMy WebLinkAboutBLDG-23-000154 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �� CITY 'YARMOUTH l; I MA DATE (July 11,2022 I PERMIT# BLDG-23-000154 JOBSITE ADDRESS 135 KATHARYN MICHAEL RD UNIT4 I OWNER'S NAME IAVEZZIE JAMES L G OWNER ADDRESS IAVEZZIE SUSAN L 145 INDUSTRY AVE SPRINGFIELD MA 01104 (TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL 111 CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 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 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. 13 NO❑ YES IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ 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 'Peter Gonyea I LICENSE# 115720 I MP❑ MGF 13JP ElJGF 13LPGI 13CORPORATION❑# SIGNATURE COMPANY NAME: (PETER R GONYEA I ADDRESS. 12 MAR I PARTNERSHIP El#' ILLC ❑#�� GARETJOSEPH RD, CITY IYARMOUTH PORT I STATE MA ZIP 026752440 TEL FAX I I CELL EMAIL none i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ��� CITY .,.._u� . ` � 7aV YW"'�''` MA DATE 7-7 4� ,;?,2 PERMIT# 23"- O! S y JOBSITE ADDRESS L3�j In 1iIa4,4 °Kcli OWNERS NAME e' [h1€ /1t 7 GOWNER ADDRESS `<3 (44IA.h j yt, IU I TEL -7I/QQ--774i5 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ❑ DUCA i IONAL ❑ RESIDENTIAL Z1-' CLEARLY Y NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-h BSIA 1 3 4 5 6 7 ° 9 10 11 12 - --I 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE I GENERATOR " _ 17 GRILLE INFRARED HEATER LABORATORY COCKS ____________.1 i MAKEUP AIR UNIT - i I OVEN " RE,CEIVED POOL HEATER • '` _ I ROOM/SPACE HEATER ilt _ ROOF TOP UNIT TEST e NIT HEATER BPAR MEN ' dy.— - {__.. _�.- LINVENTED ROOM HEATER - WATER HEATER OTHER _ I INSURANCE COVERAGE I have a current liability insurance 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 ❑ 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 Mass efts General Laws,and that my signature on this permit application waives this requirement. w SIGNATURE OF N .OR AGENT CHECK ONE ONLY: OWNER [/�-'-4G El 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. g PLUMBER-GASFITTER NAME 1.c.- %. LICENSE :r/72 0 SIGNATUF MP❑ MGF❑ JP Er JGF❑ LPG! El CORPORATION❑ft PARTNERSHIP❑# LLC COMPANY NAME � � Zic�� ❑ ADDRESS r 2 �.r, CITY �`3 ' STATE I _ ZIP G - TEL : d�d_..a '_„a.7 FAX CELL EMAIL