No preview available
HomeMy WebLinkAboutBLDG-22-005988 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK m CITY YARMOUTH MA DATE 'April 19,2022 (PERMIT# BLDG-22-005988 `f r: JOBSITE ADDRESS 17 RANDOLPH RD OWNER'S NAME IPULIDO MICHAEL C 7 G OWNER ADDRESS PULIDO SHERI A 3404 STANFORD CT ST JOSEPH MO 64506 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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 1 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 LABILITY INSURANCE POLICY❑ OTHER OF 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. 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP©MGF 0 JP❑ JGF❑ LPG(❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME. ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd. CITY W Yarmouth STATE MA ZIP 026735706 TEL FAX CELL EMAIL halloilcomDanVna.gmail.com S310N M31A321 NV1d #llW2i3d $ :33d ❑ ❑ 11Med 3H1 SV S3AH S NOliVOIlddY SIHJ oN saA S310N NO1103dSNI 1VNId A1N0 3Sf HO103dSNI 2iOd 39Vd SIH1 S310N NOI103dSNI SVO HOflO I , ___,... ! -2' a . c 1 - fi __ __ AC_ USE r UNd. QR:. APPLICATION FO1 A PERMIT TO PERFORM GAS FITTING WORK 1 —:— —___S72:r, i crne ("1 /4 iq 1,-40 c.-) /. Lt PO I3 t • ; ,,', , __, ~`T REST 7 i�h' v Pi (I. , I s....4,?* iv / _ __ G , � , _ 1 TYPE OR i 1 i- .1, �Jt1:1:�, .... tr ,,,= '.,,.. .iY f S^{ .s E./UCA i liVNAL. RESIDENTIAL I CLEARLY < NEW: R :-_IL :_ tEK CE _ _ ( PLANSSUBMITTED: YES NO Y APPLIANCES FL RS 3SM 1 ` i 2 3 4 5 ! 5 i 7 } 8 1 g I 10 i 11 ; /2 1 13 I /4 i XAVERSION BURNER _ - - - ` i t ' ` I - ' CO STOVE i • r I i t i 1 DIRECT ....._._.. _ F 3 i 4 DRYER I. 3 1 i !.,�,_� n I FIREPLACE f t t ' 1 r 1 1 , iGENERATOR ; i d ., GRILLE1. .1 ?h...INFRARED HEATER 1 72 MAKEUP AIR UNIT _ r 1 LABORATORY COCKS II h� l . - I POOL HEATER. ' I ROOM I SPACE HEATER = j 'ROOF i OP U • • �tt TES' • , i iNV ROOM HEATER I 1 t I j --7—:1--. :- '-' s�.,.` A ER HEA T E R - i , % .._ t ; , 1 t I 3 1 - I have a�r��bi�� �s��Ge ;ca p or su a. eguiva Villa e tements c i ... C ,'442 'DES 1 IF YOU C;�YES, P.�:ND CATS THE TYPE E OF COVERAGE EY CHECKING THE CAR I's E BELOWpt kL./ABILITY iFS iCcE PCUC: V } i� � no • 4 142 Cnatater of the OWNER'S INSURANCE WAIVER: f am a that the lice not have one € ;an coverage by 1 Massachusetts General Laws;and tra my signature on this parr&appE resi:areme}t i i CHECK ONE Q : OWNER AGENT SIGNATURE OF ` �OR AGENT ` •_ i E b ca- *tiic. ail t*re a is STY �-`: .' ar red regar s rx sor:are ar'tt� �. _ ° -- vt mm Kno ge 1 and that a41 pF -ic -,4 instanaBarrs parfar ;t ee Lazer petirsiL ued for i a pii n It pion • --: al. •tit:: 4f the massach te P LI it U Cote and Cilapr 142 cf the Gana—al Laws. j a F PW ER GA,SF}DER NAME AN DREW i G-t ON i vEN 151304 SIGNATURE MGF jF .s,7- LP-GI G.FS:ORATIC F { .. 37 PA.RTNERSHIP # LLC i COMPANY NAME:t HALL OIL COMPANY ice. AD3RE PT /3 - CITY SOUTH. DENNIS STATE MA Z? *660 TEL 5 98-3831 FAX 508-394-30685 Cz=f ; =.YV=IL carry ytgr :.ur: I` 1 I I 1