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HomeMy WebLinkAboutBLDG-22-005181 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH I MA DATE March 16,2022 PERMIT# BLDG-22-005181 r JOBSITE ADDRESS 58 RAINBOW RD OWNER'S NAME CIESLIK RICHARD T TRS G OWNER ADDRESS CIESLIK MARY R TRS 29 BRIARWOOD RD WALTHAM MA 02452 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL. 0 RESIDENTIAL El PRINT CLEARLY NEW: ❑ 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 1 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 0 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-GASFITTEF NAME Sean Hanrahan LICENSE# 15822 SIGNATURE MP© MGF ❑ JP[] JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. PO box 688, CITY Centerville STATE MA ZIP 02632 TEL FAX 7 CELL 7742380286 EMAIL S310N M3IA3H NVId #111/1N3d $ 33d ❑ ❑ 1IMEd 31-11 SV S3A63S N011VOIlddV SIHl ON saA S310N N01103dSNl 1VNIH AINO 3Sl 210103dSNI 210d 3OVd SIH1 S310N N01103dSNI SVO HOflOH