Loading...
HomeMy WebLinkAboutBLDG-22-005732 ra", MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (April 07,2022 ]PERMIT# BLDG-22-005732 JOBSITE ADDRESS 72 STUDLEY RD OWNERS NAME MILLER JEFFREY D G OWNER ADDRESS MILLER CAROLYN E 72 STUDLEY RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 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 ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:relocate gas meter 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 0 OTHER OF INDEMNITY 0 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 Herbert Healis LICENSE# 20177 SIGNATURE MP 0 MGF❑JP© JGF❑ LPG( ❑ CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: HERBERT M HEALIS ADDRESS. 78 STUDLEY RD, CITY S YARMOUTH STATE MA ZIP 026642906 TEL FAX CELL EMAIL hhealisl9vahoo.com S310N M3IA32I Ndld #1IW2i3d $ :33d ❑ ❑ 'Mad 3H1 SV S3AH3S NOI1`d3llddd SIHI oN saA S31ON NO1103dSNI 1VNId AlNO 3Sfl 2i0103dSNI zIOd 30Vd SIHL S310N NOI103dSNI SVO HJfOZI j 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Yarmouth _ MA DATE PERMIT# JOBSITE ADDRESS 72 Studley Rd OWNER'S NAME Miller GOWNER ADDRESS same TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT POOL HEATER R E I V E E) ROOM I SPACE HEATER ROOF TOP UNIT APR C`a 20�2 TEST UNIT HEATER UNVENTED ROOM HEATER BUILIhING UEPARMEN— a� � r WATER HEATER OTHER Gas Meter relocation 1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �/ / 1/ PLUMBER-GASFITTER NAME Herbert Healis LICENSE# 20177 �y(2� YSIGNATURE MP ❑ MGF❑ JP® JGF ❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 78 Studley CITY S. Yarmouth Ma 02664 STATE Ma ZIP 02664 TEL 508 776 5495 FAX CELL EMAIL hhealis@yahoo.com CA4-S14