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HomeMy WebLinkAboutBLDG-21-002054 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 19,2020 PERMIT# BLDG-21-002054 JOBSITE ADDRESS 130 CROWELL RD OWNERS NAME TEXEIRA JOSEPH P G OWNER ADDRESS TEXEIRA PATRICIA 301 WILLOWGATE RISE HOLLISTON MA 01746 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL IA PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:D 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 1 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE 1 1 GENERATOR ') GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: LS:y 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 © OTHER OF INDEMNITY 0 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 matthew Coleman LICENSE# 34368 SIGNATURE MP D MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MATT COLEMAN PLUMBING AND HEATIN ADDRESS. 8 Pine Pond Rd, • CITY Brewster STATE MA ZIP 02631 TEL FAX CELL 9788854343 EMAIL S31ON M31A3LI NVId # $:33d ❑ ❑ 1I1'183d 314.1.SV S3A213S NOIiVOIlddV SIH1 S" II till oN sad, S310N NOI L3 dSNI 1VNId h1NO 3Sf1 N0103dSNI 210d 3OVd SIHI S310N NOI103dSNI SVO HOfOb /OO • __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE I =u�� CITY �.� �� � ��w��-lr�,`►'V► _.,.. � �� � / PERMIT # �I �3 - is .04,?&.sy JOBSITE ADDRESS " . OWNER'S NAME loge `,, -e, k Znrc1 G OWNER ADDRESS t - ' _ _.u.._r . TELi �Qi --01,z ( 7 t -- FAX . _ Get, � , u S �� TYPE OR OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL El RESIDENTIAL. PRINT CLEARLY NEW: . l RENOVATION: `e REPLACEMENT: ., PLANS SUBMITTED: YES Ej NOL' APPLIANCES 1. 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 ,. FRYOLATOR FURNACE i 1 - 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 I ....-.3.s'r: --------- ,_._........._;si�011* ..---_. . .-a...... ...- .. .. _._ INSURANCE COVERAGE , / I have a current liabilityinsurance policyor its substantial equivalent which meets the requirements of MGL. Ch. 142 YES '�°' NO q q I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY j 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. /it A 6 b/.1 ‘ ' 6,—e' '''. ,-",,- — PLUMBER-GASFITTER NAME M.- - Fk-e.c _ ' - (t- ci, o. _.-_ LICENSE # 51-13.` SIGNATURE MP MGF JP J JGF I j LPGI El CORPORATION 1# 3 PARTNERSHIP ,#4 _ , y LLC # COMPANY NAME: A " ' ADDRESS -3—rwt7e—Pc,Tyllj, i _•. a - , ____:__ , CITY ,reoS.L� _ STATE ` ZIP om��D .- \ TEL )116 a, — t3.,._-_ FAX pyps _,,.. CELLTR-M-1.)11/4 `1 EMAIL WI Co t��Vlciy% 0,,i,,,,,, ityry,9ct-7.4 V 4 ,ilaRtidC ... i:.. i -