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HomeMy WebLinkAboutBLDG-23-001977 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK till, BLDG 23 001977 CITY YARMOUTH MA DATE October 13,2022 PERMIT# JOBSITE ADDRESS 15 KNOLLWOOD DR OWNER'S NAME CARPENTER DENNIS J G OWNER ADDRESS CARPENTER JOANNE F 15 KNOLLWOOD DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 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 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY BOND 0 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 Daniel Rossetti LICENSE# 15222 SIGNATURE MP 0 MGF ❑ JP 0 JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DANIEL N ROSSETTI ADDRESS. 19 HYDAWAY LN, CITY DENNIS PORT STATE MA ZIP 026391004 TEL FAX CELL EMAIL plumberdanr(a.pmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK (1I1V r Lr. ' ' - MA DATE /o//2 /21. PERMIT# S /y 77 T 1 O L ADDRESS /S KAir0(ON.)onh OWNER'S NAME - A)iS- E�UrCX' OWNER AI SS S�./''1� TEL —77`�- ��Co- 11w FAX TYPE OR ' �'H R r nrl r T RI PNT -- OC�UPAI�GY PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES 1 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 CI Ot,0;S a pi GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ar d a urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in omplian e h a cR1' vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE GASFITTER NAME LICENSE# /5 4 11. SIGNATURE MPGF❑ JP El JGF❑ LPG'❑ CORPORATION 11'# PARTNERSHIP El# LLC❑# COMPANY NAME 1 C' f L O&L J113r/J6 ADDRESS 0 R OX 13-S—f CITY .5:- Lt fJ�S. STATEn . ZIP O 4 6 a TEL to•r` y S Y. c&7Cr FAX CELL EMAIL f L LJr1 a Nr A f' 64.la:t'L