HomeMy WebLinkAboutBLDG-22-007377 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ZW-5 CITY YARMOUTH MA DATE June 23,2022 PERMIT# BLDG-22-007377
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JOBSITE ADDRESS 45 SWAN LAKE RD OWNER'S NAME COLLEY MICHAEL J
G OWNER ADDRESS COLLEY LYNNE M 4 DAVIES DR WAPPINGERS FALLS NY 12590 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL
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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 1
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
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 El 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.
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 Francois Paravisini LICENSE# 15211 SIGNATURE
MP 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME FRANCOIS PARAVISINI ADDRESS. PO Box 2585.
CITY Orleans STATE MA ZIP 026536585 TEL
FAX CELL EMAIL baysideat7.thecapecodplumbers.com
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JOBSITE ADDRESS -LI S SLVAM LA 1,-/- (-)PcD OWNERS NAME
G. MOM Arfaiglia • Ta.(413- 13-1Sli FAx
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have a mad~manor policy ix lie MOM aquhvigoldeh mil*mgairennie of PABL Ch.142 YES au ND 0
'trim MOW YES,PUPAE INDICATE Tie TYPE OF " . SY CHICKS*THE APPROPRIATS 110X ELM
LAMY SNOWS=POI= TA OMR 1YPE INDEMNITY 0 BOND 1:1
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OWNER MIUNIINCE WWI mai a VW Ms. 4 IIMIUMMIthe inmanos swamp'required by Chapter 142 el the
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R.UMBER-OANITTER NAME U0E148E015211 • ileilltURE .
IVO MOP 0 JP C] JOF 0 LPG!0 CORPORATION KJ#2058725139 PARTNERSHIP 0# lic 0#
COWANY NAME Beyskje Plumbing&Heating ADDRESS P.O.Box 2585
CITY Mean, STATE MA ' ZIP 02653 TEL 508-255-4555
FAX__17441114249 CELL 774-218-9484 EMAIL BaysiosirtgeaRepooPiumberszom
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