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HomeMy WebLinkAboutBLDG-22-006293 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ICITY IYARMOUTH MA DATE IMay 02,2022 I PERMIT# BLDG-22-006293 1y, JOBSITE ADDRESS 64 RAINBOW RD OWNERS NAME DASILVA MICHAEL J TR G OWNER ADDRESS THE DASILVA FAMILY IRR TRUST 39 BLENDALL ST BROCKTON MA 02302 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL I] RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 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 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 Orlando Dasilva LICENSE# 7335 SIGNATURE MP©MGF❑JP 0 JGF❑ LPGI❑ CORPORATION 0# PARTNERSHIP 0#I ILLC❑# COMPANY NAME: ORLANDO J DASILVA ADDRESS. 164-Rainbow Rd. CITY West Yarmouth STATE [MA ZIP I026735456 I TEL I FAX CELL EMAIL none S310N M3IA32J NYld #.tII 3d $ :33d ❑ ❑ 11M13d 3H1 SV SRAa3S NOI1VOIlddV SIH1 oN saA S31ON N01103dSNI 1VNId 'ONO 3sn 10103dSNI 2i0d]OVd SIHL S31ON NO1103dSNI SVO HOf102i lid=0-`;_. -if MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t 17-,0t CITY �(/ - VA A $�2i. mi- �,& MA DATE —2 / aZ PERMIT # 'Z. Z- ro Z 9 '3 JOBSITE ADDRESS t (7/ R4i 1V 00Ps<— R-P OWNER'S NAME c?kf- ' , �-�i1�L, GOWNER ADDRESS 713 'r✓ a)e.,-- /• 0 TEL��77 ' `-5Y 7 FAX TYPE OR PRINTOCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL I,] RESIDENTIAL W CLEARLY NEW: ❑ RLNNAT10N: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES 1 FLOORS—I Ball 1 2 3 4 5 BOILER - I3 1 BOOSTER CONVERSION BURNER COOKSTOVE I - A: DIRECT VENT HEATER n �N n��n" DRYER \jo L 1����xH� FIREPLACE w . Pi — FRYOLATOR Z0, t Q FURNACE GENERATOR -- • _ GRILLE ! (-- INFRARED HEATER LABORATORY COCKS -- MAKEUP AIR UNIT OVEN I - POOL HEATER r ROOM l SPACE HEATER ROOF TOP UNIT • TEST - 7-- UNIT HEATER . .-- -- ..- . . _.._ UNVENTED ROOM HEATER • WATER HEATER _ (—� OTHER INSURANCE COVERAGE 1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of N [1]IGL. Ch. 142 YES NO I IF YOU CHECKEDEl YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ 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. �t CHECK ONE ONLY: OWNER 0 AGENT [1] 'N 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 myknowledgeedge - 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. �J /1_,--i-,#4 9.44.--, _ PLUMBER-GASFITTER NAME(9g L 4"IVO& J+—P/C /1—v - LICENSE # 7 13 5-- SIGNATURE MP K MGF ❑ JP ❑ JGF El LPGI ❑ CORPORATION 0 # PARTNERSHIP El # LLC ❑ P: COMPANY NAME - il14-4trr7G? P4 544. v.,3 ADDRESS eV R*1ve CITY l,y2)-i a-(e,d�1t STATE Ili II ZIP d2-6" TEL�g '7?f .37 FAX CELL \,... EMAIL �C./ `_7 7 i '3 7 ROUGH GAS INSPECTION NO`IES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES