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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r-;,----,--41.,7__L CITY YARMOUTH MA DATE July 22,2021 PERMIT# BLDG 22 000410
1'i-
V;54 JOBSITE ADDRESS 183 PINE ST OWNER'S NAME SERPONE RICHARD L
G OWNER ADDRESS 183 PINE ST YARMOUTH PORT MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ 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❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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 Herbert Healis LICENSE# 20177
SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0#
COMPANY NAME: HERBERT M HEALIS ADDRESS. 78 STUDLEY RD,
CITY S YARMOUTH STATE MA ZIP 026642906 TEL
FAX CELL EMAIL hhealisanyahoo.com
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`2` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.<.' CITY 1'LLYlf1 B�L1 f� MA DATE / PERMIT# G-22-au-u a
JOBSITE ADDRESS /r'3" / /f74# -5-24 OWNER'S NAME SGv� d Aore
GOWNER ADDRESS sue- TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL,'f
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NOS
APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 tO 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 IRECEIVED
POOL HEATER
ROOM I SPACE HEATER JUL
UL 22
,
ROOF TOP UNIT
TEST BUILDING DEPARTMENT
UNIT HEATER • e,
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❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY ❑ BOND❑
OWNER'S INSURANCE WAIVER:lam 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 0
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 complianc- al t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# /'J1 IGNATURE
MP 0 MGF 0 JP JGF❑ LPG!0 CORPORATION❑# PART RSHIP❑# LLC 0#
COMPANY NAME ADDRESS 91r�
CITY �/�/?�!'✓'l/�if STATE___ ZIP r:7„,A�`Y El L ,r"-p•--
FAX CELL EMAIL <? AO�,ap ���