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HomeMy WebLinkAboutBLDG-22-003226 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (December 07,2021I PERMIT# BLDG-22-003226 l JOBSITE ADDRESS 56 SHORT WAY OWNER'S NAME JOHNSON RONALD R TRS G . OWNER ADDRESS JOHNSON EVELYN D TRS 56 SHORT WAY WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 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 0 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 at 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 at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Christopher Murphy LICENSE E 16548 SIGNATURE MP©MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: BLUE BEAR PLUMBING ADDRESS. 100 Corp Park Dr,Ste 1740, CITY Pembroke STATE MA ZIP 02359 TEL 7817064682 FAX CELL EMAIL S310N M3IA321 NVld #11W13d $ :333 ❑ 0 111N213d 3H1 Sb S3A213S NOI1V3llddV SIHl oN sa) S310N N01133dSNI 1VNI3 )llNO 3Sfl ei0133dSNI 10d 30dd SIHI S310N N01103dSNI SVE HJl0H •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �)= ram_ suits 1. CITY Yarmouth ` MA DATE 12/01/21 I PERMIT # 72 - 72 L. JOBSITE ADDRESS 56 Short Way_ 'OWNER'S NAME Carl & Evelyn Johnson_ i GOWNER ADDRESS Carl & Evelyn Johnson ITEL617-418-0923 FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL -INT -` EDUCATIONAL El RESIDENTIAL --7 CLEARLY NEW: RENOVATION: LI REPLACEMENT: L ' PLANS SUBMITTED: YES ] NO APPLIANCES Z FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER — _ d.� BOOSTER CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATERilium" � DRYER � FIREPLACE FRYOLATOR _ FURNACE 1 i imellig. JIMMY_ GENERATOR GRILLE 44. INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT r OVENPOOL HEATER _ ,, L_ ROOM / SPACE HEA ER __ 1 ROOF TOP UNIT --' TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ . L. . OTHER r INSURANCE COVERAGE I have a current liabiliinsurance 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 v 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 r; 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 ' a I Pertinent ro ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTE R NAME Christopher Murphy - LICENSE # 16548 SIGNATUR j MP v MGF JP __ JGF s LPGI CORPORATION # 4301 PARTNERSHIP # LLC # COMPANY NAME:, Blue Bear Plumbing ADDRESS 100 Corporate Park Dr., Ste 1740 CITY Pembroke STATE LMA ZIP;; 0, TEL 781-706-4682 FAXE ......j CELL 781-783-5244 EMAIL[info@bluebearplumbing.com