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HomeMy WebLinkAboutBLDG-22-007269 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 17,2022 PERMIT# BLDG-22-007269 JOBSITE ADDRESS 21 PAR 3 DR OWNER'S NAME CASEY THOMAS F G OWNER ADDRESS 21 PAR 3 DR SOUTH YARMOUTH MA 02664 TEL r J TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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 GRILLE 1 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 (Moses Joachim I LICENSE# 16677 SIGNATURE MP©MGF❑JP 0 JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME IMOSES PLG&HEATING I ADDRESS. 301 Buck Island Road. CITY (West Yarmouth I STATE Ma ZIP 02673 • TEL 7742511282 FAX CELL EMAIL mosesioa1974dngmail.com S310N M3IAM NVld #1IW2:13d $:333 ❑ ❑ 111183d 3H1 SY S3A2:13S NOI1V011ddV SIH1 ON seA S310N NOI103dSNI 1VNId AlNO 3Sf1 bO103dSNI b0d 39Vd SIHI S310N NOI103dSNI SVO HOf1021 ''` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ----Y_s- --- thVE •�� , - 2 6 9 G$$,n�',T�A DR SS / 091Ct /tt_ I/ OWNER'S,S N _ LULL r�l j2 DIhIJ>=R NAME �Z Yr r�1 S OWNER RE SS� �'GGl/ rde40 /v e TEL(,/" ��ZY/fs"FAX 'ttrall& DEPARTMENT iy tOCL:UP�SNCY TIYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL a CLEARLY NEW:❑ RENOVATION: k REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO APPLIANCES- FLOORS-4 esM 1 2 o BOILER _ 5 6 s 11 12 I; 1,, BOOSTER —� CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER I ! FIREPLACE FRYOLATOR FURNACEI GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER , ROOM I SPACE HEATER 7 . ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER ' I WATER HEATER OTHER j INSURANCE COVERAGE • I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 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 ❑ I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the tMassachusetts General Laws,and that my signature on this permit application waive;this requirement. . R CHECK ONE ONLY: OWNER ❑ AGENT ❑ .� SIGNATURE OF OWNER OR AGENT rl-• 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 P inert provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `Z � PLUMBER-GASFITTER NAME l"`2CP5 <70Q iu4 LICENSE aker SIGNATURE MPa] MGF E JP ❑ JGF❑P.LPGI ❑ CORPORATION❑# PARTNERSHIP E# LLC 21# COMPANY NAME Y �/`i-Cii kcA i ADDRESS 3o/1 -L?C�,5/ Ce A' CITY k-� p-Rrt/Llf l ���{ STATE itil�' ZIP VZ673 TEL �Fo2S//Z FAX r CELL' 2c/(2 ?Z EMAIL J � /ztQl' rL'e�, 1 1 i G- E--.1 G: I I 0 I H W 1 Gr1 I . I . I I I I I I I f CI I QS I r,. ti Gr1 Lli 0 4 et �--1 1 a .. . < .. . _ 1 w , �. CO GJ L.> '''''t E,,1 0 ca., io ri) (ii [--- LE._ 1 I L 0 I I 0 1 w 1 co till `aV I 0 P4 1