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HomeMy WebLinkAboutBLDG-23-004551 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rah CITY 'YARMOUTH BLDG-23-004551 rt MA DATE February 15,2023 PERMIT# JOBSITE ADDRESS 111 REID AVE OWNER'S NAME DENONCOURT ADAM G OWNER ADDRESS DENONCOURT VANDA 11 REID AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL ID 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 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❑ 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 Virgilio Silva LICENSE# 31395 SIGNATURE MP❑ MGF ❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: VIRGILIO SILVA ADDRESS. 155 SUDBURY LN, - CITY HYANNIS STATE MA ZIP 026012462 TEL FAX CELL EMAIL virpiliomgaa,hotmail.com A�o°b --'-- //9 j pee4 Cal 712 , 1 i ieo ' ,I �"ACF6USETT� UN/FORM APPLICATION FOR A PERMIT TO PERFORM ` � :J _ .. GAS FITTING TTI9+fG WORK I L `''1.5 CITY R�0rJ� �, hqA DATE 02 �S IZ 3 y JOBSIT:AD RESS A PERMIT# -2 _��c`t�1�e.i.8 A V 2-AJ t�l3UI )I G DE'�ARTM��►�i OWNER'S NAME By- _ OWNER ADr RESS 1 1 e2 r !J 4 + �NA� TYPE OR vet/ U� TEL ��Th6 _�r!5 PFUNT OCCUPANCY TYPE FAX COMMERCIAL 0 EDUCATIONAL r_ CLEARLY ❑ RESIDENTIAL[� NEW:0 RENOVATION: ❑ REPLACEMENT:❑ APPLIANCES PLANS SUBMITTED: YES❑ NO Q BOILER FLOOR, BSlul BOOSTER �_ CONVERSION BURNER DIRECT VENT f lEATER11111mm -- IRYPL = -a - FIREPLACE FRYOLATORIGGIEr =ma GRILLE HEATER �- LABORATORY COCKS roirenlialrial =MAKEUP AIR UNIT - -==POnemi OL HEATER 111111 _- I ROOF TOP UNIT ami illi ®® - UNIT NEATER imam I_ (INVENTED ROOM HEATER aleall vw I have a current liabili insurance policy or its substantialINSURANCE COVERAGE ran= I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY equivalent ich meets the requirements of MGL,.Ch.142 YES �D CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required BCha ❑ Massachusetts General Laws,and that my signature on this permit application waives this requirement. g by Chapter 142of the ,,} --� yuirEn7Eitk. 1 .• SIGNATURE OF OWNER OR AGENT CHECKONE ONLY: OWNER -.., I hereby certify that all of the details and information I have submitted or entered regardingthis 0 AGENT 0 and that all plumbing work and installations performed under the permit issued for this application will be Massachusetts State aPlumbingCode application are true and accurate to the best of and Chapter 142 of thein compliance ,' r my knowledge PLUMBER-GASFITTER NAME General Laws. - 'ertment provis rn of the -- MP 0 MGFLICENSE#/��►.��.,�Li j 0 JP �JGF . .�hvi.!v�'� SIGNATURE coMPAIVY AMES%� 0 LPGI CORPORATION 0#F PARTNERSHIP❑# CITY ' ADDRESS 1�"S U �+ �Vrs STATE M 4 ZIP (��6'�, TEL FAX CELL--� y, � C� C]J 7G EMAIL / Gr L;y/14 ' • Co 1 11 G1 • Z, • I Cr) C' 1 rya S Ciri ✓l 1 I 1 1 i 1 i 1 7 C : i w =D I VI H r,"' b r- a- - 1 co Z4 LU 1 us \ Z.[.74 `‘) Wa O wtl _1 r Iii I = lt6 t- L- 1 11 I • • \ w? 0 I 1 W I �^ 1 ci Cr' \ . . VI I0 1 P !1 11 1 I I I w / 0 z % \ I e 1 J 4 \ § / 1 1 . I I 1 i I -a =0 i \ ƒ' I \ 2 I 2 I ¢ - a \ /I m = : ® - ! .. . . . . . . . m m .. . _ ....I \. 2. . / 4 / \ / - k © Q Q f & / k / w a . . < e , � / � { 2 w • I ® / / / ! k) m Q ! \ \ — . U J m 0 6 . 0 I # rs pe a4 I V El9 AC 1USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING Vt/ORIC J 20TY /RM(3L/4 k DATE 02/4S/ 2-3 PERMIT# _-__ -Z ` �_ ���t 1 _ ~ JOBSIT AD RESS it °C.Pdi 1J AV t?NUS OWNER'S NAME , .,A BUI i C; )EPARTM NT d By. It _ OWNER AD RESS 1 +e21 d Ave, U'e TEL SO 408 3 l S 4( FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRIN ❑ DU„ATIGNAL ❑ RESIDENTIAL[� CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO Fj- APPLIANCES FLOORS-4 6S1M 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _____ CONVERSION BURNER _______ COOK STOVE DIRECT VENT HEATER _ ---j DRYER r ___ 1 FIREPLACE j FRYOLATOR _ FURNACE _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN ______I POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT _I _I= 1 _ ., TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. 1, CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT .1, 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 ,' - -ertment proves in of the Massachusetts State Plumbing Code and Chapter•142 of the General Laws. 3 /393 Lit PLUMBER-GASFITTER NAME LICENSE#f,�i''t�'�T' �.1iri..--a��! SIGNATURE MP❑ MGF❑ JP IJGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑#t LLC❑# e.COMPANY NAME 1' n Li i ..,/c�f?41 ,,, ADDRESS 153 0 unbu,ey tie CITY illyAv/t//S STATE .44 ZIP O2 .-O( TEL FAX CELL Z-1 Y ,3 01 7C EMAIL V 7. Lc;Lc; V7 G/ 0 ' &4 CD__ I1OI.4i2r¢:1 - co,,,