HomeMy WebLinkAboutBLDG-23-9594 6.4
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Atli CITY Yarmouth MA DATE 10/24/2023 PERMIT# GC DV z ' " `fr9`7
JOBSITE ADDRESS 6 Merymount Road j OWNER'S NAME ;James Igoe
OWNER ADDRESS TEL617-92ce1-0433 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL .
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CLEARLY NEW: . RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES - NO
APPLIANCES 7 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 1
FRYOLATOR
FURNACE 1
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 1 _
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 - 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
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 complia with e i ent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME Robert W Maizaka LICENSE M 10659 SI ATURE
MP - MGF JP JGF 1 LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:Robert W Maizaka — j ADDRESS PO Box 1092
CITY Orleans I STATE MA ZIP 02653 ITEL 7744 65P E I V SD
FAX CELL EMAIL bobmaizaka@comcast,net OCT z
BUILDING DEPARTMENT
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