The URL can be used to link to this page

Home My WebLink AboutBLDG-22-003241 I _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .tl g CITY YARMOUTH MA DATE December 07,2021 PERMIT# BLDG-22-003241 `, JOBSITE ADDRESS 16 HARVARD ST OWNER'S NAME Jeanette Kende G OWNER ADDRESS 16 HARVARD ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 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 John Kane LICENSE# 22755 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JOHN KANE ADDRESS. 39 MONOMOY RD, CITY S YARMOUTH STATE MA ZIP 026641984 TEL FAX CELL EMAIL sik1725no,gmail.com S31ON M31/08 NVId #1IVH d $:33d ❑ ❑ 111%13d$H1 SV S3A213S N011VOIlddV SIHl oN saA S310N NOI1O3dSNI 1VNId A1N0 3Sf1 NO1O3dSNI Had 30Vd SIHI S3LON NO1133dSNI SVO HOfON MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY S y G V YYI d VI—L MA DATE D < C -1 ( L I PERMIT JOBSITE ADDRESS Ib Ha(Vued S f OWNERS NAME Tea.t►7e114t /1ie d = - GGWNER ADDRESS S a c TEL ?BOO 60 g—' a tt FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL PRINT ❑ R�SI DENTIAL EN CLEARLY NEW:❑ RENOVATION:gip REPLACEMENT: [ PLANS SUBMITTED: YES❑ NO®- APPLIANCES FLOORS—F 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 I SPACE HEATER ROOF TOP UNIT TEST .. . . .._.. . - UNIT HEATER UNVENTED ROOM HEATER • WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY E 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 waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT 71, 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 he in compliance -th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# 3 -7ss SIGNATURE MP❑ MGF 0 JP JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME KQI1c r 1411 GI( n!9. ADDRESS 3 ri o env,/ ,2 u CITY S• Vav Ortov4-1.. STATE OVA ZIP O iZ-66 -I TEL FAX CELL 70 F 6 8S -S6S6 EMAIL S 3 1< i.1 a- 5 . 9 al G /i co tv7