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HomeMy WebLinkAboutBLDG-22-006153 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'April 26,2022 1 PERMIT# BLDG-22-006153 JOBSITE ADDRESS 52 WILFIN RD OWNERS NAME Mircha Karcha G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 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❑ 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 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 Mircha Karcha LICENSE# t5274 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑#I ILLC❑# COMPANY NAME: MIRCHA KARCHA ADDRESS. 113 WESTVIEW LN, CITY FEEDING HILLS STATE MA ZIP 010302258 TEL FAX CELL EMAIL none S310N M3IA321 N`dld #IIW2i3d $ :33d ❑ ❑ 11Wa3d 3H1 SV S3Aa3S NOIIVDIlddV SIHJ oN saA S310N NOI103dSNI lYNId AlNO 3Sf1 80103dSNI Had 3OVd SIHI S310N NOI103dSNI SVO Fiona' 19=`` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r �., . ` CITI( 57a-4y-A Q./Z,0,,,,," MA DATE d PERMIT# JOBSITE ADDRESS 571. 41: /Y1 R Ol OWNERS NAME IIEz er r,•�g g zeis, G OWNER ADDRESS r/3 L•&�Tv,c /i n W.W. 9/3 ) 3 4(17 5'-7 TYPE OR �nx PRINq. OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL NEW: RENOVATION: ❑ REPLACEMENT: El PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-4 BSM 1 2 34 5 6 o BOILER - 9 10 11 12 13 L1L BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER L - DRYEP, - —— FIREPLACE ' FRYOLATOR —— FURNACE GENERATOR / GRILLE ` INFRARECiHEATER —� LABORATORY COCKS _______I MAKEUP AIR UNIT • • OVEN • POOL HEATER _L_ ROOM/SPACE HEATER I/ ROOF TOP UNIT -- _L TEST e ltJ UNIT HEATER - 1---- LINVENTEG ROOM HEATER / WATER HEATER BUIL ING - "PAR—MEN_ I OTHER INSURANCE VERAGE I have a current lia btli insurance policy or its substantial equivalent O which meets the requirements of MGL Ch.142 YES ❑ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY El BOND 0 OWNERS 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. 3 SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER 0 AGENT El 1, 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 provisio f the �` Massachusetts State Plumbing Code and Chapter 142 of the LI l 122 General Laws. �o PLUMBE -rASFITTEP,NAME j ///2!,A Q /1' ' CElSE# Js SIGNATURE MP , MGF❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME l'[ jq j�(j(,f q/ S /G-41 j7`j J yT ADDRESS .1 3 L-C?e _j7-1/) c;Gts' f j�yT e CITY /` e-e-10 ;kr Ji/l STAT E TE ji7/,'1 ZIP U/c�..3 O TEL FAX CEL( /)) 3 Y2? 5'?EMAIL ROUGH GAS I SFECT'I�I'`� IfQJES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes NO THIS APPLICATION SERVES AS THE PERMIT fl FEE: $ PERMIT # PLAN REVIEW NOTES