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HomeMy WebLinkAboutBLDG-23-003356 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c CITY 'YARMOUTH MA DATE December 16,202; PERMIT# BLDG-23-003356 ti �4 JOBSITE ADDRESS 960 ROUTE 6A OWNER'S NAME ORMON BROTHERS REALTY TRUST G OWNER ADDRESS M DALE ORMON TR 27 FARM HILL RD DENNIS MA 02638-2454 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 OTHER 1 OTHER DESCRIPTION:broiler 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 El 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 'Joseph Jasie Jr I LICENSE# 13422 SIGNATURE MP❑ MGF © JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JOSEPH C JASIE JR ADDRESS. 116 APACHE DR, CITY 'YARMOUTH PORT STATE MA ZIP 026752102 TEL FAX CELL EMAIL 'lasielacomcast _ ........., MASSACHUSL I I S UNIFORM APPLICATION FOR A FERMI TO PERFORM GAS FITTING WORK Ft.--F4f---..-7----,- , •••-2- t-kr.... MA DATE /z-i4- a Z- PERMIT rt4,--g- r-- 0 ---2__L. /___ iIk„, clEc 1 6 MIT ADDRESS 9 . —. .c..., 1 -,- OWNER'S NAME / i AI• :.._)Prl-e-Ci_ler/tetiki L,t3i er.4 Si OWNE . DDRESS l-ii (m,(6-2.07 .N. ,,ge,„„),5-,,,, -7EL .538- 6 3.42- ,o 2-FAX BeAri.2LoRL Di NG i.)E AR1 MI fil T -=e6Clii'AI4CY TYPE COMMERCIAL•K r--C-._C A-.,:.,-'-‘4*- 7 RESIDENTIAL U CLEARLY NEW:c3 RENOVATION:0 REPLACEMENT: . PLANS SUBMITTED: YES 0 APPLIANCES-1. FLOORS..4 ' BElbA 1 1 2 3 1 4 5 5 , 7 fi 9 10 11 12 13 LL BOILER I 1 3 i i 1 BOOSTER i-- CONVERSION BURNER : I COOK STOVE DIRECT VENT HEATER 1 DRYER t. I FIREPLACE I : FRYOLATOR I ' , i L FURNACE I ' GENERATOR I ' • , GRILLE 1 ' INFRARED HEATER LABORATORY COCKS i i • 1 - ' MAKEUP AIR UNIT ' — 1 ' ; OVEN -4 POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER i I LINVEINITED ROOM HEATER WATER HEATER — OTHER , 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivMent which meets the requirements of MGL Ch.142 YES NO r-7 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE EY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY([gt OTHER TYPE INDEMNITY 71 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee thes not have the insurance coverage required by Chapter 142 of the Massachusetts -9 l aws . * that my signature on this perrrk application waives this requirement. CHECK ONE ONLY: OWNERS AGENT ..:.} ---, 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 lair `- and that all plumbing work and installations performed under the permit ssued for this application will be incrV Pertinent provision Or te ."-- Massachusetts State Plumbing Code and Chapter 142 of the General Lal-ls. - PLUMBER-GASFI i I ER INIAME-3 _ip\r-N-----5--..ae k ,,., LICENSE# A 3-<\ S-GNATURE MP fl MGF[ JP El JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP Li# IL C 0 4 COMPANY NAME 3-7* c --‘-:%-r• \.`c-- _. ADDRESS/4 ::,4c-72-4- -> CITY )1/--....c ^t--4-C_)*,..)- --trm --1 ____ .7 )e--2,-3/-D - STATEiljVt .., ZIP , ?:...L. e TEL FAX CELL .7Z:4