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HomeMy WebLinkAboutBLDG-23-001497 ,,2 ¶ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' BLDG-23-001497 �, CITY YARMOUTH J MA DATE September 20,202 PERMIT# =f7 JOBSITE ADDRESS 1 STABLE LN OWNER'S NAME Dave cirillo G OWNER ADDRESS 1 STABLE LANE YARMOUTH PORT MA 02675 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 I COOK STOVE DIRECT VENT HEATER T DRYER FIREPLACE FRYOLATOR • FURNACE GENERATOR 1 GRILLE 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 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 El BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have:he 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 Ronald Conte LICENSE# 15696 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RONALD M CONTE ADDRESS. 283 Cranview Rd, CITY Brewster STATE MA ZIP 026312241 TEL FAX CELL EMAIL rcontemechanicalna gmail.com S310N M3IA321 NVId #lIWN3d $ 33d ❑ ❑ 111n1J3d 3H1 SV SAS NOIlVOIlddV SIH1 oN SaA S310N NO1103dSNI 1VNId AINO 3Sf1 b0103dSNI dOd 30Vd SIHl S310N NO1133dSNI SVO HOfOd _-----_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • rizT I�hr, DATE l /I `( /Z Z '�`�=:��1 a� PERMIT� Z S - I r 7 I C , IT AD RESS -1 S ±Ck )e, L. O , OWNER'S NAME J L f r f) �} OWNER DRESS 4- BJ�t1LltiNi; E PA R 1 M E N T S ab '� TEL 7�7^ Z Z 3(Z 3 FAX fey .--- •V Yfttl�r JC TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL [I CLEARLY NEW:rx RENOVATION: ❑ REPLACEMENT: ❑ c PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS BSM 1 2 s 1 5 F BOILER g s to 11 12 t; t BOOSTER CONVERSION BURNER BURNER COOK STOVE �— DIRECT VENT HEATER DRYER FIREPLACE FRYDLATOR I FURNACE GENERATOR GRILLE �r — I • INFRARED HEATER - —, - LABORATORY COCKS i --� MAKEUP AIR UNIT — OVEN "—I POOL HEATER ,J ROOM/SPACE HEATER ROOF TOP UNIT TEST . . UNIT HEATER UNVENTED ROOM HEATER WATER HEATER �j OTHER — I 1 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES liZ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING TI-IE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [f 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 waive;this requirement. SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER ❑ 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 '\p v/A I_ () (LC A) 7 C LICENSE# / b `I L SIGNATURE MP IMF❑ JP 1 JGF ❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑ti COMPANY NAME P`, M. COW--r M C. C H A IJ i c A L ADDRESS Z j C Ca 1\ V r CITY (- W 34--e K STATE ./`'(A A. ZIP 0 26 3 / TEL FAX CELL 5 0 rr — 2 3 1 -`1 71 y EMAIL 2C 0 0) e µe C 1/0✓1, C 09 . ! (cm ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES