The URL can be used to link to this page

Home My WebLink AboutBLDG-22-006798 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE IMay 24,2022 I PERMIT# BLDG-22-006798 11 JOBSITE ADDRESS 1041 ROUTE 28 OWNERS NAME WG YARMOUTH REALTY LLC G OWNER ADDRESS CIO WALGREENS ATTN:TAX DEPT P 0 BOX 1159 DEERFIELD IL 60015 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES El NO 0 FIXTURES FLOORS-c 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 ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:roof top unit heater INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY El 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 Jarrod Costa LICENSE# 15707 SIGNATURE MP El MGF 0 JP 0 JGF El LPGI ❑ CORPORATION 0# PARTNERSHIP El# LLC❑# COMPANY NAME: JARROD COSTA ADDRESS. 1655 Fall River Ave, CITY Seekonk STATE MA ZIP 027712040 TEL FAX CELL EMAIL rvan(altriantlleref.com S31ON M3IA321 NVld #1IWH3d $:33d ❑ ❑ iR11213d 3Hl SV S3A2i3S NOIIV011ddV SIHI oN seA S310N NO1103dSNI 1NN13 AlNO 3Sfl H0103dSNI 2JOd 3OVd SIHl S310N NOI103dSNI SVO HOflO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 5/ / ,"LA MA DATE V/6 O2d2- PERMIT # /1AY 1J6eNtiV AD IR SS /o'CJ/ /�r(1- . .. ;, `�/ram OWNER'S NAME B tyr I N G Dp `' E S 'T{I,' /)e jn �c) A f Llis/&o/.eTE L FAX /A G"LJ PRINT OCCUPA PE COMMERCIAL EDUCATIONAL [l RESIDENTIAL C CLEARLY NEW: (l RENOVATION: REPLACEMENT:kr PLANS SUBMITTED: YES (l NO l APPLIANCES -1 FLOORS- BSM 1 2 3 4 j 5 6 7 8 9 10 1 11 12 13 14 BOILER BOOSTER CONVERSION BURNER _ I i 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 .— J J J v_✓ __ OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES, J NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Z 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 n 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 LICENSE #4/4/176 7 SIGNATURE MP MGF , y JP n JGF S LPGI f y CORPORATION ri # PARTNERSHIP LJ # LLC ❑ # COMPANY NAME -7r/Itnijk J ADDRESS `tip- sr- I 'kW c , J-- SI- CITY rpm ) ey- STATE /i1 )4" ZIP 0 4)- 1 , ] TEL 5 i ci L // FAX CELL EMAIL