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HomeMy WebLinkAboutBLDG-22-002513 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK mn f` BLDG 22 002513 itkr, CITY YARMOUTH G MA DATE November 02,202' PERMIT# JOBSITE ADDRESS 340 HIGGINS CROWELL RD OWNER'S NAME TOWN OF YARMOUTH G OWNER ADDRESS 1146 ROUTE 28 SOUTH YARMOUTH MA 02664-4463 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS BSM 1 _ 2 3 4 5 6 7 _ 8 9 10 11 12 13 14 BOILER _ 3 BOOSTER CONVERSION BURNER _ COOK STOVE _ 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 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❑ 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 anthony centrella LICENSE# 840449 SIGNATURE MP❑ MGF Q JP 0 JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: ADDRESS. 82 rockmeadow rd, CITY uxbridge STATE ma ZIP 01569 TEL FAX CELL EMAIL tcentrella(@,camhvac.com _M MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _';_= ° -- est Yarmouth MA DATE 26 October 2021 PERMIT# OCT 2164111 ADDRESS 340 Higgins Crowell Road OWNER'S NAME Town of Yarmouth i. !R .inic IIOW IffIRMDDREoS 1146 Route 28 TEL 508-398-2231 FAX 508-398-2365 A PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ CLEARLY NEW: El RENOVATION: ❑ REPLACEMENT'.'] PLANS SUBMITTED: YE NO El APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 3 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER U DRYER FIREPLACE ' FRYOLATOR —e FURNACE ..k_ GENERATOR GRILLE INFRARED HEATER I\'' LABORATORY COCKS 41 MAKEUP AIR UNIT OVEN POOL HEATER 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 NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIO 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT El I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate t b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co li with all erti ent ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Piry PLUMBER-GASFITTER NAME LICENSE# 4400 , SI N TURE MP El MGF❑ JP❑ JGF El LPGI ❑ CORPORATI# PARTNERSHIP El# LLC❑# COMPANY NAME CAM HVAC & Construction ADDRESS 116 Lydia Ann Road CITY Smithfield STATE RI ZIP 02917 TEL 401-232-7230 FAX 401-232-7290 CELL 508-505-8601 EMAIL tcentrella@camhvac.com tcentrella@camhvac.com