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HomeMy WebLinkAboutBLDG-23-000469 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK WT-sitgl CITY YARMOUTH MA DATE July 28,2022 PERMIT# BLDG-23-000469 ff JOBSITE ADDRESS 423 NORTH MAIN ST OWNER'S NAME GORDON CAROL A(LIFE EST) G OWNER ADDRESS 423 NORTH MAIN ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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 1 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 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 Anson Celin LICENSE# 32655 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ANSON CELIN ADDRESS. 26 Capt.Blount Rd, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL ansoncelin aC�yahoo.com S310N M3IA311 NVld #11W213d $:33d ❑ ❑ 'IVOEd 3H1 SV S3A213S NOI1VOIlddV SIHl ON seA S31ON N01103dSNI 1VNIJ AINO 3Sl 210133dSNI UOd 30Vd SIH1 S3lON NO1133dSNI SVO HOl021 — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK —°w: ----'� CITY _r..Ain 4cvtnA,gig MA DATE 2 ri-2Z PERMIT#2'3— 0:`t(aS JOBSITEADDRESS L Z 3 I\i 6citiink, s 54.- OWNER'S NAME at1- I t Chu GOWNER ADDRESS t-23 flCd f1'i .n b 4— TEL G 11--- I"I61/ FAX FAX TYPE OR 1/ PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL(I�' CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: ET PLANS SUBMITTED:YES❑ NO APPLIANCES 7 FLOORS BEM 1 2 3 4 5 6 7 9 9 10 11 12 BOILER P 13 14 BOOSTER CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER - DRYER L._ FIREPLACE FRYOLATOR FURNACE �_ GENERATOR GRILLE INFRARED HEATER t• LABORATORY COCKS _ r tq F MAKEUP AIR UNIT - 14/ F,D _ OVEN r— POOL HEATER f JUL 2 7?O1Y —, ROOM/SPACE HEATER ROOF TOP UNIT _ TEST -, BUI_DING U EHARTME_VT ... . • UNIT HEATER _ INVENTED ROOM HEATER • WATER HEATER OTHER INSU NCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 87NO❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IV OTHER TYPE INDEMNITY ❑ BOND 0 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 CHECK ONE ONLY: OWNER❑ 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 test of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be In c Pence with all Perlin provision of the Li I Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#3 1 5 • MP❑ MGF❑ JP 2 JGFF 0 LPGI❑ CORPORATION❑# PARTNERSHIP❑# SIGNATURE # COMPANY NAME l c t 1 ri I" IU�plp I, Z � �l CITY N6irm0' 5rt;,E��n .t AlADDRESS � Cit6'I�tin i lo�.,it}— rcl FAX STATE/ A ZIP TEL $ -24o-C(/C.:2,— CELL EMAIL C Lai .criCF el f1i1D' &U,d ItOU H GAs INS ON NC)TIi;S THIS. PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑• ❑ FEE: a PERMIT# MEAN I REVIEW NOTES • • •