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HomeMy WebLinkAboutBLDG-23-00268 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE (July 18,2022 'PERMIT# BLDG-23-000268 ` JOBSITE ADDRESS 44 ADAMS RD OWNER'S NAME SUAREZ-HERRERA MARGARITA G OWNER ADDRESS 44 ADAMS ROAD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL� RESIDENTIAL 0 PRINT CLEARLY i 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 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 1 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 LABILITY 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 LICENSE# 32655 SIGNATURE MP❑MGF❑JP© JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ANSON CELIN ADDRESS. 26 Capt.Blount Rd. CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL ansoncelinWyahoo.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES - APPLICATION# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -CITY t- 1/1k7,110 lJ MA DATE ri / 72_ PERMIT# G L IJbB ADDRESS 1_1(f A(ort11.71 f ''b OWNER'S NAME FrinODING DPW/kWt RE S L I4 r1- 5 I TEL i j AX OCCUPANt PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOEr APPLIANCES 1 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 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0 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 compl' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. •3—t__. PLUMBER-GASFITTER NAME Ali,NA CI(k j LICENSE# `�� �� SIGNATURE MP❑ MGF❑ JP JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME: C<' `� ,� ��`t vy,ib, ,,,r ADDRESS • L(- Ce.4.(0 q, CITY 7)(.1) \ `(�� r trZeick STATE PIZIP OL,-(n(,,i TEL _-`a.q j FAX CELL EMAIL prl `11 l ICI G/G M6CJ (U/1) THIS APPI ICATIC)N SFRVFS AS THE PFRMIT YFS NO FEE:$