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HomeMy WebLinkAboutBLDG-22-000236 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ?V ,r CITY YARMOUTH MA DATE July 14,2021 PERMIT# BLDG-22-000236 JOBSITE ADDRESS 6 SOMERSET ST OWNER'S NAME DORNIG ELAINE M EXC G OWNER ADDRESS 6 CYPRESS CT LOS ALTOS CA 94022-2650 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: D RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES 0 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 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 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 Curtis Sears LICENSE# 10175 SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: CURTIS F SEARS ADDRESS. lPo Box 370, CITY Yarmouth Port STATE MA ZIP 026750370 TEL FAX CELL 5083620656 EMAIL none MASSACHUSETTS ETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w p ' VTYD /ftz. vMOu 1l MP, DATE 7 1 l'� 12 c' I PERMIT 4 g1466 -22-W06\a, ,T ..._....VJOGBSTESDDRESS 4 -s0M f2$ £-i RP OWNER'S NAME p0�"'r 6-' 4 2JTe�NN R.r DDRESS TEL FAX eI,J [ I �I1ARFy�.AIdCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL(� CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES] NO ® I APPLIANCES 4 FLOORS 6SM 1 2 3 -1 5 6 7 8 9 10 '11 12 '13 14 BOILER ______I BOOSTER —I CONVERSION BURNER, I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE IFRYOLATOR ' FURNACE GENERATOR. GRILLE ' INFRARED HEATER —I ._ / LABORATORY COCKS I MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER. ROOF TOP UNIT TEST I ._ - _ __.. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I I I OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES ❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [/ OTHER TYPE INDEMNITY ❑ BOND ❑ 1 • 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,arid that my signature on this permit application waives this requirement. J CHECK ONE ONLY: OWNER ❑ AGENT ❑ •-, SIGNATURE OF OWNER OR AGENT i,:: 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 comp lance with all Pertinent provision of the,z' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /✓ Lo PLUMBER-GASFITTER NAME LICENSE 4 /, rzi-- SIGNATURE MP ! -- MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION❑4 PARTNERSHIP❑# LLC❑4/ COMPANY NAME ADDRESS x 3 70 CITY yi12 '1O 1.)-Tip a a,r STATE /1/I` ZIP OZ[.7.) TEL s 0(--34 2--oca FAX CELL EMAIL I i 1 G1 Fza E"I G I 2 J F I I GO I I a I i I ..a G a 0 . F=a >— 1 VI I Fad Ci w ELI C qt I— M ra,1 e� w - .. . g o c C o o F4 H ca_ ca.. US 1i I U I I w 0 H V I E°1 I L) I Cld CO I Z i fr.t , �C, a o f 1 1