Loading...
HomeMy WebLinkAboutBLDG-23-001496 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1a CITY YARMOUTH MA DATE (September 20,2021 PERMIT# BLDG-23-001496 7. `" JOBSITE ADDRESS 135 KATHARYN MICHAEL RD UNIT4 I OWNER'S NAME IAVEZZIE JAMES L I G OWNER ADDRESS AVEZZIE SUSAN L 145 INDUSTRY AVE SPRINGFIELD MA 01104 TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT❑ PLANS SUBMITTED:YES 0 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 FIREPLACE FRYOLATOR FURNACE - - GENERATOR 1 GRILLE _ _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ _ OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT - _ TEST 1 _ _ 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 12 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 at 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 0 JP❑ JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP ❑#I ILLC D# COMPANY NAME: RONALD M CONTE ADDRESS. 283 Cranview Rd, CITY Brewster STATE MA ZIP 026312241 TEL l FAX CELL EMAIL Ircontemechanical(ogmail.com S310N M31A32i Ndld #1.1 d $ :33d ❑ 11W2i3d 3H1 SV SAS NOI1VOIlddV SIHL oN seA S310N N01103dSNI 1VNId AlN0 3Sf1 W103dSNI 1Od 30Vd SIHI S310N N01103dSNI SVO HOf10H �r—R—T� V Iry ssAcHusETrs UNIFORM CO 0 •C M APPLICATION FORGA PERMIT TO PERFORM GAS FITTING WORK 20_ fT YG{ /t'1 c3 U MA DATE t / 19 / Z Z PERMIT# 7-3— i(19 c. t3U LILI pl _ wiEPAFT �-IT ADDRESS 3 5 KCti ill 0.ry Ai M1CHaeI s .OWNER'S NAME U 1 t /t 4 _f2_Ie Hy _.. `� OWNER ADDRESS 3 S KQH1)6 rvn,/ Mi C�atrI Ra. TEL re'/Z2�3iO3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL /PRINT EDUCATIONAL El RESIDENTIAL[V CLEARLY NEW: RENOVATION: L] REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑ APPLIANCES 1 FLOORS—+ BSM 1 2 3 1 5 6 7 g BOILER 9 10 1'I 12 13 1" BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ DRYER _ FIREPLACE FRYOLATOR FURNACE _ GENERATOR � , GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN I t POOL HEATER _ • ROOM I SPACE HEATER ROOF TOP UNIT TEST - . NIT HEATER UNVENTED ROOM HEATER • WATER HEATER OTHER INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [21 NO I IF YOU CHECKED YEs,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY [Jf 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT El -` 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 R d do,,L o Colo T'p LICENSE#156 9 6 SIGNATURE MP 0 MGF❑ JP 91 JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP L]# .nLLC❑# COMPANY NAME F,,_`,C(U 1J T(- M . C NAN I c Q L ADDRESS ZZ 3 C nl yl J ; e w ,J . CITY R rQ W S`I'e(Z STATE ✓i-{A ZIP 0 26 3/ TEL FAX CELL 5o'-23. "97Jy EMAIL CD )e CYlct rC ryt q r i. C nAi UGII GAS �PE€: P�( � TIOTI;,S THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No • THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: PERMIT tI • PLAN REVIEW NOTES • • • • •