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Home My WebLink AboutBLDG-22-003568 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK x" CITY YARMOUTH MA DATE December 28,202'PERMIT# BLDG-22-003568 II..EY JOBSITE ADDRESS 111 PERCH POND WAY I OWNER'S NAME Marcia Ross G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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 GENERATOR 1 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 LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY BOND ❑ 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. 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 'Mark Moran I LICENSE# 120786 SIGNATURE MP❑MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑#I I PARTNERSHIP ❑# LLC❑# COMPANY NAME: (MARK R MORAN I ADDRESS. 116 BRAMBLE BUSH DR, CITY IFORESTDALE I STATE MA ZIP 026441017 TEL ' FAX CELL 1 1 EMAIL I S310N M3IA32I Ndld #f11n1d9d $ :33d ❑ 1101213d 3H1 SV SIVAS NOILV011ddV SIHL oN saA S310N NO1103dSNI 1VN13 AlNO 3Sfl H0103dSNI HOd 39Vd SIR! S310N N01103dSNI SVO HOfOb - AC;HLJSETTS UiNIFORIVI APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK FtW=----==-11-tL ,:t cif 'CITY--— r/va _196 MA DAT= C/ ) PERMIT # .�;.�•-- DEC 2 __I E AD RESS � �� " r OVLNER'S NAME l` BUIQ G 3 pPANRADDTEL FAX PRINT uCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL I,—] RESIDENTIAL F CLEARLY NEW:'a RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES .1 FLOORS-I BSIv1 1 ? 3 1 5 6 7 ° 9 10 •1'1 12 '13 14 BOILER BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE I FRYOLATOR FURNACE GENERATOR / I GRILLE I i INFRARED HEATER T j LABORATORY COCKS i MAKEUP AIR UNIT j OVEN —i POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST _ . . _ UNIT HEATER - UNVENTED ROOM HEATER 1 j WATER HEATER I l OTHER ' 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL. Ch. 142 YES NO (J I IF YOU CHECKED YES, PLEASE. INDICATE THE TYPE OF COVE -4E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY n BOND n 1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the i 1 Massachusetts General Laws, and that my signature on this permit application waives this requirement. 3 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 , he best of myknowle `` and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all e inert provisi n of tl�e dge 40 Massachusetts State Plumbing Code and Chapter '142 of the General Laws. _ '4?zi . 17-*‘--- -1 1 — PLUMBER-GASFITTER, NAME�� /A.)r--0,(// LICENSE ?Al SIGNATURE l�� MP ❑ MGF I JP JGF n LPGI ❑ CORPORATION ❑ f PARTNERSHIP ❑ #r LLC — COMPANY NAMEc piz/' v--,Ar ,, ADDRESS /` 1/'� /� �� CITYro✓Cp�� STATE ZIP !' TE L �' 2 5t/ FAX C •�' ELL EMAIL I I G on C 1 i 1 GI 67.1 I 1 0 t i C) 62.c 1 cr./ I 4 11 1 I j ri bad I W 0.1 1 co CY 1 Z CA. co Il9 I I- 1 u.... I 1 1 ti 1 1 61 1 (rr� I 1+4}} I co I �+4 aM V 1 f