HomeMy WebLinkAboutBLDG-22-006826 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
kr,),,11 I CITY 'YARMOUTH I MA DATE IMay24,2022 (PERMIT# BLDG-22-006826
t}6� JOBSITE ADDRESS 2 MERGANSER LN OWNER'S NAME Andrew Condon
G OWNER ADDRESS 2 MERGANSER LN WEST YARMOUTH MA 02673 I TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111
PRINT
CLEARLY NEW: m 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/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 El 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 LESTER WADE LICENSE# 4569 SIGNATURE
MP❑MGF Q JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑#I ILLC❑#
COMPANY NAME: LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD,22 CAPTAIN ISIAHS RD
CITY COTUIT STATE MA ZIP 026352702 TEL
FAX CELL EMAIL info(a,ccipgenerators.com
S310N M9IAT:1 NVld
# $ :33d
El El 1111213d 3H1 Sd S3/113S NOI1VOIlddV SIHI
ON SGA
S310N N01103dSNI 1YN13 A1N0 3Sf1 10103dSNI 2iO3 30Vd SIHI S310N NOI103dSNI SV9 HOflO I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY Q' W10 u MA. DATE {�<<- PERMIT# � 4 s Lt;
JOBSITE ADDRESS - m " 5 e r OWNER'S NAME ithl re ul C vt-ole
GOWNER ADDRESS Si Q Cl-be TEL a-355= 7/3 3FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
MEW
CLEARLY 'NEW:Q RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO
APPLIANCES FLOORS-• BSM i 2 3 4 5 6 7 8 9 10 1 11 12 13 14
BOILER _
•
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY-COCKS I
MAKEUP AIR UNIT d
OVEN
POOL HEATER
'ROOM/SPACE HEATER
ROOF TOP UNIT I
TEST
UNIT HEATER
UNVENTED ROOM HEATER _
WATER HEATER
OTHER
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 ❑
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 ❑ 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 to the best of knowiedge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance ' all P i on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASF!I i tti NAME L ES+'e r I t)a.C£ LICENSE# 4 5 tc SI RE
MP❑ MGF® JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME °(-Ccp e..C,e et can.p-ect ce c1.4.-i..r ADDRESS a-3 BcN.e etv t Rat.
CITY NA.SU 4i-e.e STATE AM ZIP (o ill TEL 50 V-4-ri $�
1 FAX KA A CELL 50 -15 0—Egq i5 EMAIL i T,44 c� ey��b =-h�rs. cc err