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Home My WebLink AboutBLDG-22-004405 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k-_'rif CITY YARMOUTH MA DATE February 08,20221 PERMIT# BLDG-22-004405 - JOBSITE ADDRESS 1 HARDING LN OWNER'S NAME VICSIK PAULETTE N G OWNER ADDRESS 1 HARDING LN WEST YARMOUTH MA 02673 TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS-s 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 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 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY El 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 Hyland I LICENSE# 33776 SIGNATURE MP❑MGF❑JP El JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#[ COMPANY NAME: 'MATTHEW HYLAND I ADDRESS. 1127 COPELAND ST. CITY IBROCKTON I STATE MA ZIP 023016958 TEL FAX I I CELL EMAIL Ihylandhvaca,gmail.com S310N M31A3e1 NVId #.I1A2i3d $ :33d ❑ ❑ iI1N213d 3Hl SV SAES NOLLV3IlddV SIHI oN s8A S310N NO1103dSNI 1VNId AlNO 3Sl 210103dSNI 210d 3OVd SIH1 S310N N01103dSNI SVO HOflO I • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . 1. ;$1-.P CITY 1 r\ I,Sji�� RAr i\{ MA DATE a " 7- PERMIT# Ztcr JOBSITE ADDRESS L OWNER'S NAME ()/VAP. C lL�1K OWNER ADDRESS TEL 5O'-7�7"JJ � FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(:Sc PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Esf PLANS SUBMITTED: YES❑ NO in APPLIANCES T 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 ( I GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER IRECEIVED ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 FEB U / AIL UNIT HEATER I 1 UNVENTED ROOM HEATER BUILDING ME VT - -----r- WATER NEATER By. - OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES le NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2/ OTHER TYPE INDEMNITY ❑ BOND El 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 a at the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance I ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 14l1anr11 LICENSE#31776' 7 SIGNATURE MP El MGF❑ JP[ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPA Y NAME `'LAtA kli\C , ADDRESS (-K.). r91 e 1 �L• CITY KAAJtoOK STATE if,A ZIP 6r�3(a2 TEL FAX CELL ]7'1'S6i-7�6 EMAIL k.�.�s !�U/Il, 6 i is• C v1 5