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HomeMy WebLinkAboutBLDG-21-002736 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - .1_ o CITY YARMOUTH I MA DATE (November 13,202(I PERMIT# ►= BLDG 21 002736 JOBSITE ADDRESS 138 SEMINOLE DR I OWNER'S NAME IKOCHKA DONALD V G OWNER ADDRESS IKOCHKA DEBORAH E 38 SEMINOLE DR YARMOUTH PORT MA 02675 I TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ElRESIDENTIAL CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 FIXTURES FLOORS PLANS SUBMITTED: YES 0 NO BOILER BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 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 1 OTHER DESCRIPTION:fire pit 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 John Gilmore MP© MGFLICENSE# 13699 ❑ JP 0 JGF❑ LPG! El CORPORATION # MIN PARTNERSHIP COMPANY NAME: PLEASANT BAY PLUMBING INC. ❑ PARTNERSHIP 0# _LLC ❑#� ADDRESS. 43 B Independence Way, CITY Brewster STATE MA ZIP 02631 TEL FAX111 CELL EMAIL pleasantbayplumbinqAcomcast.net 77, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t V CITY: �l�lR�1-4�c*� A. DATE l 7.� PERMIT# J1,7)e" . /Co (2(74, JOBSITE ADDRESS: �S' a•!.i �C {..-Nii t- OWNER'S NAME: 00 U (rL,1LA OWNER ADDRESS:G TEL: TYPE OR FAX: PRINT OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW& RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ Np4g.__ APPLIANCES-. FLOOR Bsmt 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 COCK MAKEUP AIR UNIT c OVEN POOL HEATER ROOM/SPACE HEATER `I ROOF TOP UNIT fi TEST 1 Z UNIT HEATER I UNVENTED ROOM HEATER WATER HEATER - F2.6 PIi ‘ - INSURANCE COVERAGE • I have a current ii bill insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY NOV 0 5 202 OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coveragerequired byC#> Massachusetts General Laws,and that my signature on this permit application waives this requirement. ' �---���2 rJ_ tE NY SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 hereby certify that all of the details and information I have submitted(or entered)Knowledge and that all plumbing work and installationse permitr issued dg orth isa apcacon are true and a rate to withh best P ofrt nmy e provision of the Massachusetts State Plumbing Code andCha Chapter 14 under the GeneralsLaws r this applicatb all Pertthent PLUMBER/GASF(TTERNAME:< • - `: ( ` LICENSE# 13(0` SI ATU RE COMPANY NAME: , � , PUS. yY c_ j �,,��,,� ADDRESS:�� �j� -�`� CITY:�Q[�a_.��_ � . ��1��L`* • '�`A-�L —_"__ _____.. STATE: {{�� ZIP: 1-G "xt"'_"S` � FAX: TEL: CELL: EMAIt: MASTER JOURNEYMAN 0 LP INSTALLER CI CORPORATION 0#3 � �'�C�- —�- PARTNERSHIP❑# LLC 0#`_ E iv' /L- AZDDiz ss: /‘ -ate