HomeMy WebLinkAboutBLDG-23-002738 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
; ` CITY 'YARMOUTH I MA DATE (November 16,20ZI PERMIT#- BLDG-23-002738
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JOBSITE ADDRESS 16 ST ANDREWS WAY OWNER'S NAME IDEMARCO JOSEPH
G OWNER ADDRESS DEVINE JOANN 34 BLUE HILLS TRAIL GLASTONBURY CT 06033 TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT PLANS SUBMITTED:YES 0 NO El
NEW: m RENOVATION:❑ REPLACEMENT: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 1
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 ❑ NO El
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 'Andrew Leighton I LICENSE# 116130 I SIGNATURE
MP 0 MGF ❑ JP 0 JGF 0 LPGI 0 CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#I I
COMPANY NAME: 'ANDREW R LEIGHTON I ADDRESS. 120 Brewster Rd, I
CITY IW Yarmouth 'STATE IMA I ZIP 1026735706 I TEL ' I
FAX 1 1 CELL I I EMAIL lhalloilcompanyagmail.com I
d t 4‘110& MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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=uti= CITY vC c i 7
,_- -f- __o ,, MA DATE ! / PERMIT# 2 3- 2 7 3 P
JOBSITE ADDRESS_ _Si' R '- 4 OWNER'S NAME on nn _-- - _1G
OWNER ADDRESS ''
TYPE OR OCCUPANCY TYPE COMMERCIAL n EDUCATIONAL Ei RESIDENTIAL[ '
PRINT
CLEARLY NEW: RENOVATION:Li REPLACEMENT:Li
PLANS SUBMITTED: YES 0 NOr
APPLIANCES 1 FLOORS-' ssta lia 2 KR 4 • 6 7
BOILER— 9 10 13 12 13 14
' ' -
BOOSTER WWW - >M�?
CONVERSION BURNER [ � EI � l
COOK STOVE WW j I(
DIRECT VENT HEATER
DRYER t l J
FIREPLACE -ii" ` I�IM��^ s ;flfi
etiMS
FRYOLATOR �----��- :
FURNACE -_ _ - -
' _, i
GENERATOR � �Mi�� j��f ilini
� 1
111.
GRILLE ��:��+ M � -___.- -,
INFRARED HEATER `
INFRARED
HE - __ -N' IMIONI— -
ii
MAKEUPAiR UNIT _ `OVEN - -- - - - � f
-
POOLir
HEATER `W IC ' f M _
MIS i
ROAM/SPACE HEATER � ,�
JJ
lam;`_ ` .'°'��
i
ROOF TOP UNIT MitilitillittertliUMWMOINIMWEIMAINNOWIMPAPPC
KIMJIMMINIMEMINIMEW:VAXIMINMINA
UNIT HEATER _
�f MIM
UNVENTED ROOM HEATER
WATER HEATER f -��-'M MM i I (
WMM
OTHER
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f
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WW.I.E..**WiliiiiMtailliist MOW
ERAGE
I have a current liability Insurance policy or its substantial equivalent whicINSURANCE h Vmeets the requirements of MGL,Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY O:i HER TYPE INDEMNITY BOND 1_I j
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 CHECK ONE ONLY: OWNER ® AGENT Fl
i hereby certify that all of the details and Information I have submitted or entered regarding this applicati are tru and - cure : a the..st of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will a in cam ranc-with- Pertin= t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _
_SA, '
PLUMBER-GASFITTER NAME
�4/1/1 cez� 6 U6,T. _j LICENSE# iro(
SIGNATURE
MP fa, MGF 0 JP I] JGF 0 LPGI® CORPORATION[ #},).;Y c-__I PARTNERSHIP /#�-1 LLC[,�# _,
COMPANY NAME:!
L.�, .< QlG C'6 .riugc, .....I ADDRESS L! 3a_ 'C _ 13 , F .. _..
���1R.,s_ v.o...__._._..
CITY L Ste. c
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FAX k`i '..F.f.'f�l CELLI_____�•- _- j
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