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HomeMy WebLinkAboutBLDG-22-005102 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 15,2022 PERMIT# BLDG-22-005102 JOBSITE ADDRESS 39 MARINERS LN OWNER'S NAME Steve mechlinski G OWNER ADDRESS 39 MARINERS LN YARMOUTH PORT MA 02675-1231 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS-n BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 • LABILITY 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 Charles Stockdale LICENSE# 24526 SIGNATURE MP❑MGF❑JP© JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME CHARLES L STOCKDALE ADDRESS. 256 MAYFAIR RD, CITY SOUTH DENNIS STATE MA ZIP 026602803 TEL FAX CELL EMAIL S31ON M3I/132i NYld #iIIN2i3d $ :33d ❑ ❑ 1111d3d 3H1 SV S3/1213S NOIlV011ddv SIHI oN saA S31ON NO1103dSNI 1VNId AlNO 3Sf H0103dSNI 2iOd 3OVd SIHI S31ON N01103dSNI Sd9 HDflO I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _>tW "U 9- CITY Yarmouth MA DATE 317/2022 PERMIT# JOBSITE ADDRESS 39 Mariner's Ln. OWNERS NAME Mechlinski c� GOWNER ADDRESS same TEL 774-254-4493 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 UNIT HEATER 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 I NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' 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 cornpf with ertine ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Charles Stockdale LICENSE# 24526 SIGNATURE MP MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: Charles Stockdale ADDRESS 256 Mayfair Rd. CITY S.Dennis STATE MA ZIP 02660 TEL 508-398-2843 FAX CELL 774-208-1613 EMAIL clsplumb@gmail.com