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HomeMy WebLinkAboutBLDG-21-002163 aka 204 Old Townhouse Rd MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .�, C: CITY YARMOUTH MA _DATE (October 21,2020 PERMIT# BLDG-21-002163 ti (POT /)Lid /L kIA) t JOBSITE ADDRESS OWNER'S NAME 'CORMIER GENE A G OWNER ADDRESS 'CORMIER RICHARD B 204 OLD TOWNHOUSE RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL El CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO FIXTURES FLOORS--0 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 2 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❑ 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 'Michael Maloney I LICENSE# 111247 MP© MGF 0 JP 0 JGF 0 LPGI ❑ CORPORATION #I SIGNATURE ❑ I PARTNERSHIP ❑# ILLC ❑#I COMPANY NAME: 'MICHAEL R MALONEY ADDRESS. 12508 CRANBERRY HWY, CITY IWAREHAM I STATE 'MA I ZIP 1025711003 I TEL I FAX I I CELL 1 I EMAIL 'maloneyplumbingta7,comcast.net '�— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ._ --) CITY WG`;I Vorr%l 'iufli MA DATE AV / /c/d PERMIT#a0— �-- vG�-� JOBSITE ADDRESS a d 7 dig Mt, r+ T7bvYt cl OWNER'S NAME l,h/`I i eorttlier GOWNER ADDRESS Copt a a! 4/2(MS TE5CE"'ll(p"Y5y% FAX TYPE OR OCCUPANCY TYPE COMMERCIAL t EDUCATIONAL PRINT ❑ RESIDENTIAL❑ CLEARLY NEW:E RENOVATION: ❑ REPLACEMENT: (N PLANS SUBMITTED: YES❑ NO SX i i APPLIANCES 1- FLOORS—+ Bailin 1 _? 3 4 5 6 7 8 9 10 '11 12 13 14 I BOILER _______I BOOSTER CONVERSION BURNER COOK STOVE 4_ DIRECT VENT HEATER --I DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE j-- INFRARED HEATER L--- LABORATORY COCKS MAKEUP AIR UNIT _`.. . OVEN POOL HEATER �--- ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER t OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NNO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY yl 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR ONE ONLY: OWNER ❑ AGENT ❑ 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 Z Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME S chat I �- /o LICENSE# /l'//'y(�r ,l, ilexizi_ T ✓ c 1, I1a.�� SIGNATURE MP IN, MGF❑ JP )❑ JGF❑J LPG! ❑ CORPORATION Kli 307 PARTNERSHIP❑# LLC Na/6Ytc(y /"/ Vk '1 k ADDRESS �J COMPANY NAME I � ��� C rG�{�jr�,r� /��i�,W C� 1 CITY WO Ir,hC 61 STATE Yll A- ZIP d 25 TE V r a __ FAX ��,� _ �191 cFu cg-31� 64 3 EMAIL at 6Ylrw nkili4 eCam