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HomeMy WebLinkAboutBLDG-22-005135 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK »`- CITY YARMOUTH MA DATE March 16,2022 PERMIT# BLDG-22-005135 Ir� JOBSITE ADDRESS 1151 ROUTE 28 I OWNER'S NAME Monzur Kaftan G OWNER ADDRESS I02670 TELI TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO 0 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 2 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 ❑ NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY 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 'Anson Celin I LICENSE# 32655 SIGNATURE MP 0 MGF 0 JP© JGF 0 LPG' ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IANSON CELIN I ADDRESS, 126 Capt.Blount Rd, I CITY 'South Yarmouth I STATE MA ZIP 02664 TELI I FAX 1 I CELL 1 I EMAIL 'ansoncelin(yvahoo.com S310N M3IA321 NYld #iJIN2:l9d $ :33d ❑ ❑ 111183d 3H1 Sb S3A213S NOI1d01lda SIHl oN saA S31ON NOI103dSNI 1VNId NINO 3Sf1210103dSNI JOd 30Vd SIHI S310N NOI103dSNI SVO HDI102i R 460: ISSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY tti s, - MA DATE 3 U-Cam— PERMIT # ZZ Si r Ni°AWf0 2 22 1 LA c _ JOB SITE ADDRESS I1 61/11 OWNER'S NAME h/C.4r 1, •t"f�r1 BUILDI _ NAR1WARR. ADDRESS Li r z, `>y — TEL � .! ��� s TYPE OR PRINTOCCUPANCY TYPE COMMERCIAL EDUCATIONAL 7 RESIDENTIAL CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: 51 PLANS SUBMITTED: YES n NO APPLIANCES _l FLOORS-4 BSM 1 2 3 4 5 6 7 0 9 10 11 12 .I, 1 BOILER BOOSTER � { CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYDLATOR 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 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL. 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 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Masszar_hus.etts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER fl AGENT 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. . n sor, C e_ n # ��Sr PLUMBER-GASFIT TER NAME LICENSE s SIGNATURE MP ❑ MGF 7 JP JGF f( LPGI E CORPORATION ❑ F PARTNERSHIP n # LLC ❑ # COMPANY NAME G.1 l amtiA(0 , n 6+nJ ikod-r.- DRESS Cam" t ?ill/An Ra CITY 5c14.. qt-ovicia.fftSTATE M A ZIP v2--,C7 TEL S j- L{ �" L FAX CELL EMAIL f— (&1/1 (.6-to f—ke -- Cid-1 I' _ 1 1 1 G2 0 . C) I h-, I C) I 0.t I 1 I 1 1 I 1 1 a Z i in 1 Cr.) Cr it g F 6s1 111 Mi 1— i I .. owi �. w In 04 CI Pa Q I �w C"..) E a_ C].. < ve' U3 El 1 !— I I GO 0 I I Z G I E• C.) 1 W as co V I V I 0 C4 I