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HomeMy WebLinkAboutBLDG-23-005782 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � 6 CITY YARMOUTH MA DATE April 19,2023 PERMIT# BLDG 23 005782 JOBSITE ADDRESS 23 PAULA LN OWNER'S NAME MAZZA ALBERT J G OWNER ADDRESS MAZZA HELEN T 11 EAST CROTON DR LAKE CARMEL NY 10512 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III 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 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 Andrew Barbato LICENSE# 35287 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL barbatoandrew1 agmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -kW:" CITY: lEArTh � MA. DATE: 11 I)/ )� PERMIT#2-3 5 7`'L JOBSITE ADDRESS: ) 3 OWNER'S NAME: Kzvu(l 13 cc f&,- �v GOWNER ADDRESS: ..)*" Pc—dIK- in TEL: )0 '3)4-3`t(G FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL Efi PRINT CLEARLY NEW:11 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO L?l APPLIANCES-1 FLOOR-. Bsrnt 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 I FRYOLATOR FURNACE (- GENERATOR L . GRILLE V INFRARED HEATER w I LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER J ROOF TOP UNIT ' TEST Z UNIT HEATER 1,1 UNVENTED ROOM HEATER WATER HEATER 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 have 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 Er AGENT ❑ SI NATURE OF OWNER OR AGENT 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 nce with�IIert rent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `� PLUMBERIGASFITTER NAME: ArjGkc" I•l 7"�c LICENSE#35z0a-) SIGNATURE/ jj / COMPANY NAME: 1S(-, �r7 f t_oi4)rT,�41c•0 ADDRESS: I S 3 e`3 (rc• <, Mcic+<It'x� .: CITY: (Ktrk'k.(j-bor'l STATE: ( -- ZIP: 01.34c, FAX: TEL: 50C--AS'`.)--7 CELL: EMAIL: be 54Ga,Wr�„ � 7x., MASTER❑ JOURNEYMAN 5:6 LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# ""— E1ri,iL. wz z •ss 4/CD i___APR 14 2023 BUILDING DEPARTMENT By - ---- CIS 3 it �'