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HomeMy WebLinkAboutBLDG-23-001495 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 10`,;,INI, CITY YARMOUTH MA DATE September 20,202 PERMIT# BLDG-23-001495 JOBSITE ADDRESS 1 BELLE OF THE WEST RD OWNER'S NAME tim strano G OWNER ADDRESS 1 BELLE OF THE WEST RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ 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 1 FIREPLACE FRYOLATOR FURNACE 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❑ 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 Ronald Conte LICENSE# 15696 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RONALD M CONTE ADDRESS. 283 Cranview Rd, CITY Brewster STATE MA ZIP 026312241 TEL FAX CELL EMAIL rcontemechanical angmail.com S310N M3IA321 NVId #1IW213d $:33d ❑ ❑ 11Wii3d 3H1 SV SRAd3S NOI1VOIlddV SIH1 oN so), S31ON NO1103dSNI 1VN1J AINO 3Sfl N0103dSNI 210d 3OVd SIH1 S310N NO1103dSNI SVO H9110?J J C, • L' " -- SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1E I Ct J WI C v v l MA DATE 1,/l`� / z Z. PERMIT# 2 3- i Li 4 1 S��'�! � 1aC)E ITE ADDRESS � p dl �-• la 0 1");e. w L 5+ 0~ OWNER'S NAME I M S -f___- /1 B ILDI EPART9 €RADDRESS RP)1 e ll -c- *11 -e "1/‘) I Pal-TEL u, _; _ . FAX Yy. T u NCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL 0 CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: �C PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-+ SCM 1 2 3 1 5 F BOILER g s 10 11 12 l; BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR -- FURNACE GENERATOR, 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT • OVEN — POOL HEATER -4_, F iI ROOM;SPACE HEATER ROOF TOP UNIT -- i TEST • ______I , UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER r {-____________ INSURANCE COVERA GE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES g NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [vJ 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 Cha ier 142 of the 4 Z P General Laws. Z,.-, PLUMBER GASFIT fER NAME 0 ill A I d CO✓l-+e ;,� LICENSE i� 1 S 6 9b SIGNATURE MP 'J MGF❑ JP 2 JGF ❑ LPGI Cl CORPORATION El 4 PARTNERSHIP❑it LLC COMPANY NAME R. M (,� !J T F. Q� ❑ N1 -�I-1414'1 CAL _ ADDRESS 2�3 C T� 4 View 0_()- CITY 1g 5-be R STATE P4. ZIP 0 Z� 3 1 TEL FAX CELL 0 '2 3 7 1 ?1 EMAIL 0 .M C II G I C tk L W1u) Co Rigign GAS Ii+(SPEC'TIQPd N(3'I'ES THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: PERMIT# PLAN REVIEW NOTES