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HomeMy WebLinkAboutBLDG-23-002557 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I ` CITY YARMOUTH MA DATE November 08,202; PERMIT# BLDG-23-002557 JOBSITE ADDRESS 71 OLD HYANNIS RD OWNER'S NAME EZZAOUI ABDELAAZIZ G OWNER ADDRESS 71 OLD HYANNIS RD YARMOUTH PORT MA 02675-1767 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 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 thomas queally LICENSE# 33582 SIGNATURE MP 0 MGF 0 JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ITHOMAS V QUEALLY ADDRESS. 1105 Plain St, CITY (Pembroke STATE MA ZIP 023593230 TEL I FAX I CELL I EMAIL Isurfsupplumbingna,gmail.com M MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK +_ s %`tom_."_ ," CITY y4{' C1�j i �— MA DATE 'l--lj - 2,7 - PERMIT JOBSITE ADDRESS 71 OLb Hyhor-7h/S' it-cl OWNERS NAME OWNER ADDRESS -79 1,' G,- y- TEL TEL TYPE OR FAX MINT OCCUPANCY COMMERCIAL❑ EDUCATIONAL ❑ RESIDENT CLEARLY NE' • RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-I FLOORS- BSM 1 2 3 1 5 6 BOILER 8 9 10 11 12 13 1' BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR —� FURNACE INN GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS ______-- --_____I _—�- MAKEUP AIR UNIT OVEN - II POOL HEATER ROOM SPACE HEATER �� slw��� TEST - _ AL ■■ ROOF TOP UNIT UNIT HEATER ,• UNVENTED ROOM HEATER WATER HEATER -�- II I - OTHER 'Mel 1 y L - - INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 Y : • NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG• FCKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLI OTHER TYPE INDEIVINITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the CMassachusetts General Laws,and that my signature on this permit application waives this requirement. I. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ID AGENT El 7.I-, 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 complianc with all Pertinent provision of the I Massachusetts State Plumbing Code and Chapter 142 of the General Laws. g Lt1 PLUMBER-GASFITTER NAME LICENSE RSA 'IGNATURE MP ❑ MGF❑ JP JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP COMPANY NAME 7bQcç C ❑��t LLC❑�: f ADDRESS CITY cr7S9�-i STATES ZIP 923 / TEL FAX CELL f "/f EMAIL b h CCAS a)