HomeMy WebLinkAboutBLDG-23-005881 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE April 24,2023 PERMIT# BLDG 23 005881
JOBSITE ADDRESS 61 BAYBERRY RD OWNER'S NAME Steve Hetzel
G OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES 0 NO ❑
FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER ,
_DRYER
FIREPLACE 1 .
FRYOLATOR
FURNACE
GENERATOR .
GRILLE
INFRARED HEATER .
LABORATORY COCKS ,
MAKEUP AIR UNIT
OVEN .
POOL HEATER
ROOM I 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 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 Steve Gilmore LICENSE# 13699 SIGNATURE
MP El MGF 0 JP❑ JGF 0 LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: ADDRESS.
CITY I STATE ZIP I TEL
FAX I I CELL I I EMAIL Ipleasantbavolumbino a(�,comcast.net
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
IM'W
Vros CITY �14 _ -�J� � MA DATE 't'A 7/2- PERMIT# 23 5 '
JOBSITE ADDRESS l�^O R‘,..j%`0 (2a' OWNER'S NAME
GOWNER ADDRESS TEL FAX
•
TPRI T OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
ET
CLEARLY
NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES k NO❑
APPLIANCES 1 FLOORS—• 6SIul 1 2 3 1 5 6 s 1 9 10 •1'1 12 '13 1R
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
l DIRECT VENT HEATER �i
DRYER '
FIREPLACE ( i
FRYOLATOR
FURNACE
GENERATOR .
GRILLE H
1 _,
INFRARED HEATER
LABORATORY COCKS .R.. c E 1 V C ) --
MAKEUP AIR UNIT
OVEN —H
POOL HEATER ' " 1$ W
ROOM I SPACE HEATER —~ I
ROOF TOP UNIT BUI DING utHH-t11 E ,
TEST ... .. . I I ". :_ ---
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER - _ _ �-
OTHER
f/� INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Al...._ 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.
•
CHECK ONE ONLY: OWNER ❑ AGENT ❑
• , SIGNATURE OF OWNER OR AGENT
r1. I hereby certify that all of the details and information I have submitted or entered regarding this application ar accur e to best of my knowledge
`:- and that all plumbing work and installations performed under the permit issued for this application will be in c plia . 't i it provision of the
�'` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
4)
PLUMBER-GASFITTER NAME g&NE&VM-C J2-L---- LICENSE#tV SIGNATURE
F o`{ PARTNERSHIP❑ LLC❑#
WV MGF❑ JP El JGF❑ LPGI❑ CORPORAT101 a# #
COMPANY NAMEFV 1vV-k.VLt t- ADDRESS 4J s -A% C �� L AV—,
CITY V 5 .-- STATE ZIP C?2(,� 31� TEL j
FAX • CELL (?``iI -7 22. 4 4-S EMAIL \6—tt" '`� c3 :� !l"�,..c.... O t'.
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