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Home My WebLink AboutBLDG-22-005113 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q CITY YARMOUTH MA DATE March 15,2022 PERMIT# BLDG-22-005113 JOBSITE ADDRESS 17 SHELTERED HOLLOW LN OWNER'S NAME HAYES EDMUND M G OWNER ADDRESS HAYES DOROTHY E 17 SHELTERED HOLLOW LANE YARMOUTH PORT MA TEL 02675-1544 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:Cl 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 1 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 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 El 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 LESTER WADE LICENSE# 4569 SIGNATURE MP El MGF El JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD, CITY COTUIT STATE MA ZIP 026352702 TEL FAX CELL EMAIL ,• �r� i e USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I CA,L MA DATE - a PERMIT# Z - 5 I a`)AIJREI3s Il l 2 a^Z 11 G---1 ) la,_ OWNERS NAME C-4- vv"t i n; OWNE.ikrAbOtt6S I cc.. abe VC. TEL >C 4 I-- -1 cLi oFAX TXPiVOR PUNTOCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:1E1 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO Cl APPLIANCES 1 FLOORS-4 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 I • 'ROOM/SPACE HEATER • ROOF TOP UNIT 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 E NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE Of COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY 0 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 1 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 y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance 'th all Pe t vi on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME L .S+err WC(C( LICENSE# 4 5 fc 9 SI RE MP❑ MGF® JP 0 JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Cap e_ cc e tea.�j�� d z. 1 ?t,Lc—Li— ADDRESS a 3 Bea, etc)a'vi RS, CITY Oka stf►,p- .F STATE MA ZIP `C -( 41 TEL 50 Y t FAX aOtA CELL 50S-X50-- 'S g ICJ EMAIL ; .�,�� Cc d 5 a✓yA tO CS.