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HomeMy WebLinkAboutBLDG-22-007243 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • CITY 'YARMOUTH I MA DATE 'June 15,2022 I PERMIT# BLDG-22-007243 I�La' JOBSITE ADDRESS 64 RAINBOW RD OWNER'S NAME DASILVA MICHAEL J TR G OWNER ADDRESS THE DASILVA FAMILY IRR TRUST 39 BLENDALL ST BROCKTON MA 02302 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 1 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 OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY 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# 13512 SIGNATURE MP 0 MGF❑JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME ORLANDO J DASILVA ADDRESS. 39 BLENDALL ST, CITY 'BROCKTON I STATE MA ZIP 023021740 TEL FAX I I CELL I I EMAIL none S3ION M3IA32:1 NVld #±lV i3d $ :333 ❑ 0 II1n1a3d 3H1 SV S3AH3S NOI1d3IlddV SIHl oN saA S310N NOI103dSNI 1VNId ,LINO 3Sfl 2J0103dSNI 80A 30Vd SIHI S310N NO1103dSNI SVO HOfl02l ` sE I V FAD CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Jw ��" 15�� fF t� �Ia/ y-y MA DATE 6./ - /3- A Z PERMIT# Z1- . / -i3 JOBSITE_A DF ESS OWNER'S NAME g IL NG c�ARTMENT 'QWI4FRADDRfr5S •e//Z 4",/ ram.' �, RJ TEL '-2-7e 54'3 7 FAY. ITITE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONALE_ PRINT ❑ ❑ RESIDENTIAL RI CLEARLY NEW 9 RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO ❑ APPLIANCES FLOORS-I slut 1 ? 5 61 9 10 1'I 12 I3 14 BOILER 1 BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER L______I DRYER, X -_ FIREPLACE i FRYOLATOR FURNACE GENERATOR • GRILLE I INFRARED HEATER -- LABORATORY COCKS i MAKEUP AIR UNIT —� • - I OVEN POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER WATER ROOK! HEATER �� WATER HEATER OTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO D 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 I` Massachusetts General Laws,and that my signature on this permit application waives this requirement, I. 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.��L 1/ PLUMBER GASFITTER NAME A1tZ -' rvl7G'T Skit g 1 ,2 '` ` 51 L I/a LICENSE# 7 j`3 5 SIGNATURE MP E MGF❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME a73.Z- n ni(7o t 7"; _C:',4 S,Z v ADDRESS CITY STATE ZIP TEL FAX CELL EMAIL 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