HomeMy WebLinkAboutBLDG-22-005117 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE March 15,2022 PERMIT# BLDG-22-005117
JOBSITE ADDRESS 33 SPARROW WAY OWNER'S NAME TINNEY-HERBST CLAYTON
G OWNER ADDRESS C/0 KENDRICK PHILIP&JANET 2 BONNIE DR EXETER NH 03833 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ 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 ❑ 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.
S GNATURE 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❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD,
CITY COTUIT STATE MA ZIP 026352702 TEL
FAX 1 CELL EMAIL
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MU* USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-. _.' ..--CITY UZ r( u`-" ) MA DATE -I`�-)- )- PERMIT# Z L Sift
p,R JOSSITE ADD N 3 3 S?a-r rr)vt) ik,a,.I OWNER'S NAME PIA, i p K
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'gam OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL lil
CLEARLY NEW:Q RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 1. FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 I 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER •
COOK STOVE
DIRECT VENT HEATER .
DRYER •
FIREPLACE
FRYOLATOR
FURNACE .
GENERATOR ,-----
GRILLE .
INFRARED HEATER V
k
LABORATORY.COCKS 1 • V
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 El NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ® OTHER TYPE 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.
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 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 ' all P t vi on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFIT TER NAME U-S- € - ik)(ZCL e LICENSE# 4 5(c q Si d�t1RE x
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MP 0 MGF® JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME Cc:.p C.L£a cEx.t,e"c('.:-c1-4- . t.c-ti.r" ADDRESS a_3 Bo.:%eLc-,r't-► R.S,
CITY Oka.S A 1-f f STATE IAA . ZIP t -L' -ii TEL 50 --'h 1—ii sS 1
FAX toIA CELL 50S-150-S'S• & _ EMAIL ,•n-ri.C) c .i? cse,� o-c_-ICE,es. Cc. ey
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