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HomeMy WebLinkAboutBLDG-22-006638 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE !May 17,2022 I PERMIT# BLDG-22-006638 JOBSITE ADDRESS 15 DENVER DR UNIT D4 OWNERS NAME LEE RENEE E G OWNER ADDRESS 15 DENVER DR UNIT D4 WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 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 1 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 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 LABILITY INSURANCE POLICY 0 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 !William Heath I LICENSE# 12021 SIGNATURE MP©MGF 0 JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: 'WILLIAM 0 HEATH I ADDRESS. 1265 GREAT WESTERN RD,45 Main Street CITY 'Sandwich 1 STATE MA ZIP 026452428 TEL I FAX I I CELL EMAIL Ibillsboat330 dnumail.com S310N M3IA3H Ndld #111N213d $ :33d ❑ ❑ 111183d 3H1 SV S3A2i3S NOILVOIlddV SIHl oN SO/ S310N N01103dSNI 1VNld AlN0 3Sfl 2101O3dSN1210d 39Vd SIHI S310N N01103dSNI SVO HJflO 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 47 CITY: yA.ti" ` MA. DATE:ma /E 4Ly PERMITS L 3•a h r JOBSITE ADDRESS: I s 1) Iv'-t i 1-t Jr-c OWNER'S NAME:Pewee_ L e G OWNER ADDRESS: vA' r 4r TEL: 5 t LY;���'71/0 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL[] EDUCATIONAL ❑ RESIDENTIAL[t PRINT CLEARLY NEW:© RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-1 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 OVEN _ POOL HEATER ROOM/SPACE HEATER .J ROOF TOP UNIT fi TEST .Z UNIT HEATER L 1.44 UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 12 OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee ices 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 0 SIGNATURE OF OWNER OR AGENT 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 ail Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: IA)'i-c-t•'a m N-'-,TA, ''L LICENSE# I'n/L-V 4/ SIG-NATURE COMPANY NAME: •t Ff 5611 iJ%tC (G4.‘"In n� - ADDRESS: C).--- f'7'" -' f n.C' T CITY: ):1 4,9 W L, STATE: 1 h ZIP: U 2 S`G 3 FAX: TEL ?. / 91.70 CELL S(4 72( /G'v j"` EMAIL: . '/s S_/77- 0 �� 2-P7 .C:• MASTER[JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# tic❑# h2 4-/[, ,9bi;2E SS :