HomeMy WebLinkAboutBLDG-22-003357 f '1-1 CIV
ASSACHUSETTS UNIFORM APPLICATION FO ERMIT TO PERFORM GAS FITTING WORK
c e CITY IYARMOUT 1 MA DATE December 13,20211 PERMIT# BLDG-22-003357
JOBSITE ADDRESS 36 CAPT RYDER RD OWNERS NAME INASCIMENTO LIDIANE DO
G OWNER ADDRESS 136 CAPT RYDER RD SOUTH YARMOUTH MA 02664 ,TEL'
TYPE OR OCCUPANCY TYPE
PRINT COMMERCIAL❑ RESIDENTIAL El
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 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 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. 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 'Henry Zimmerman 'LICENSE# 115569 I
MP IDMGF ElJP 0 JGF❑ LPGI 0 CORPORATION 0#I I SIGNATURE
PARTNERSHIP ❑#I 'LLC ❑#I COMPANY NAME: HENRY J ZIMMERMAN
ADDRESS. PO BOX 640,
CITY
bnrrarall STATE MA ZIP 025380640 TEL
_FAX 1 CELL EMAIL hjzimmerman anpmail.com
- -_� - CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`' _:tom CITY 1
>,: DE MA DATE z-/� PERMIT
. V� C 1 MATE, DD RESS `�
C , ( 11 1 c e / /M LR'S NAME V.,/ z r`�-� p i
BU G.p_ 1 &A DPESS E TEL
TEL FAY,
PRINTOCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
❑ RESIDENTIAL ii(
CLEARLY
NEW:Ci RENOVATION; ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES 1 FLOORS-- 6SIJ 1 ? 3 45 g 0 1
BOILER 9 10 I'I t?
BOOSTER -`�
1 —
CONVERSIONCONVERSIONBURNEBURNER _ i
COOK STOVE
DIRECT VENT HEATER
DRYER
j
FIREPLACE --
FRYOLATOR
FURNACE
GENERATOR ___L
GRILLE
INFRARED HEATER
LABORATORY COCKS ___________
MAKEUP AIR UNIT ________I
OVEN
POOL HEATER I 11i
ROOM/SPACE HEATER ' I
ROOF TOP UNIT
TEST
i
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER I_�
OTHER
—II '
INSURANCE COVERAGE
I have a current liat___Lultinsurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES ❑ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E 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
fMassachusetts General Laws,and that my signature on this permit application waives this requirement. i.
'� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER AGENT El
"I� I hereby certify that all of the details and information I have submitted or entered regarding this application are true arptiaccurate to the best
and that all plumbing work and installations performed under the permit issued for this application will be in corn ii cei '
Massachusetts state Plumbing Code and Chapter 142 of the General Laws. of my knowledge
Li / II Pertinent provision of the
PLUMEER-GASFITfER NAME I���'%
LICENSE# ``.
MP IGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION ❑# 1 SIGNATURE
• PARTNERSHIP❑tr LLC❑II:
COMPANY NAME e Si* .--)
CITY %r 7.41�Ci� �i ADDRESS /' ec- _G7
STATE MP\ ZIP C Z
FAX CELLrc EZ �/%" TEL r
'`�� EMAIL �tJ "�i t'?1 Y1'1 t'_c i C �A > C'1'3'�
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