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BLDG-22-001684 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k„ICITY YARMOUTH MA DATE September 23,202 PERMIT# BLDG-22-001684 L_f JOBSITE ADDRESS 14 SHANNON CT OWNER'S NAME ROBERTS WILLIAM R G OWNER ADDRESS ROBERTS ELIZABETH ANN M 115 CHILSON RD WILBRAHAM MA 01095-1225 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 0 NO ID 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 Ross Halket LICENSE# 34296 SIGNATURE MP❑ MGF 0 JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: ADDRESS. 169 Morgan St, CITY Holyoke STATE MA ZIP 01040 TEL FAX CELL EMAIL rhalketta7,prodsky.com ... RECEIVED SEP 2 10201.6.6-0 . . 32 a 2,...,i_ (Abo-)t.P I ILDINn i)[-elo- iAAFNT ....„-----s -.....111ASSACK14ETT8 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t',..5q 0 =,....... - .:„..c.;,,tv*V.• NI Altri=-' CITY: _SOull4 YokeinefuTt4 MA. DATE: liZ 2.1 LI PERMIT# 21-- I 1 1 * JOBSITE ADDRESS: 14 CbiAMAigiu eerAve OWNER'S NAME: hamed i lee_ easaly G OWNER ADDRESS; Ill Fe*eui.4 Dew*. Lvot&hrIL TEL:till)S3t-4.74-t- FAX:r4a) 696-Zfi 69 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALO' PRINT CLEARLY NEW:0 RENOVATION:CI REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO tia APPUANCESL FLOOR-4 I Berm 1 2 3 4 5 6 1 7 8 9 10 11 12 13 14 BOILER I ‘ '' BOOSTER 111111111 11011111111111111111011 111111111111111112.1110 ,... CONVERSION BURNER COOK STOVE 4 11111 • DIRECT VENT HEATER MI 111111111.'' DRYER MIN 111111110111111111111111111111111111101111111111 FIREPLACE 1.11111111111 11111110111111111111011101111 1111011111111111111111.1111111 ill 1,'; FRYOLATOR FURNACE GENERATOR 111111111 ! 111 III GRILLE kil INFRARED HEATER 111111111111111111 W11111111111111111111111111111111111111111 'Ca LABORATORY COCK 111111111111111 NMI all MAKEUP AIR UNIT MMIIIIIIIIIIIIIIIIIIIIIIIIII r4.... OVEN 1111 POOL HEATER - ROOM/SPACE HEATER NI ROOF TOP UNIT TEST III UNIT HEATER I i j UNVENTED ROOM HEATER WATER HEATER 1111111111111111.11111101111111.1111. 1.1111111 11.111111. I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO la If you have checked YES,please Indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY CI OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S IN..*• CE WAIVER:I am aware that the licensee does not have the insurance coverage requited by Chapter 142 of the , sac e 1. lik.- .,and that my signature on this permit application waives this requirement. / CHECK ONE ONLY: OWNER I4 AGENT LI m -E6F lir - hereby certify that all of the details and information I have submitted for entered)regarding this appicati. = - e and rate to the best of Knowledge end that all plumbing wort(and installations performed under the permit issued for this app ....tio •II in I ce Chant provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBERIGASFITTER NAME: R0i4 A NA L Kiri T , - LICENSE It COMPANY NAME: ADDRESS: , ' in 1 4.;. s-7 CITY:_4_4,..y.illrel._ _ STATE: frki. ZIP: 40/010 FAX TEL: CELL:kr') 2,4(e-Q13et EMAIL MASTER 0 JOURNEYMAN Ea LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LLC CI# E/77,v c.,. 091)Dzc-ss: . - -,.