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HomeMy WebLinkAboutBLDG-22-006382 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , � CITY YARMOUTH MA DATE May 04,2022 PERMIT# BLDG-22-006382 JOBSITE ADDRESS 17 MOSS RD OWNER'S NAME James Kennedy G OWNER ADDRESS 66 ARNOLD RD WELLESLEY MA 02481 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: © RENOVATION:D 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:firepit 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❑ 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 Paul Dacey LICENSE# 21740 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: PAUL J DACEY ADDRESS. 50 PLATT ST, CITY ABINGTON STATE MA ZIP 023511406 TEL FAX CELL EMAIL pdacevph1 angmail.com S310N M31A321 NVId #1IW213d $:333 ❑ ❑ 1I11213d 3111 SY S3Ai13S NOIlv011ddtl SIHl oN seA S31ON NO1103dSNI NNW AINO 3Sf1 U0103dSNI NOd 30Vd SIH1 S3 LON NO1103dSNI SVO H0f10d MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -,='�= y 4 r )- u //K 2�—c:3 SrL ==t7= CITY: �� U MA. DATE: P RMIT# JOBSITE ADDRESS: 17 A1D59 Y' S OWNER'S NAME:(; f6'5 k/11/140.01,7 GOWNER ADDRESS: TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El APPLIANCES-1 FLOOR-' Bsmt 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 _ , INFRARED HEATER LABORATORY COCK , MAKEUP AIR UNIT OVEN / R E C E II V E D POOL HEATER _ ---- ROOM I SPACE HEATER ROOF TOP UNIT 61 TEST — UNIT HEATER BUILC I NG D PARTM. NT iiy UNVENTED ROOM HEATER WATER HEATER 4t)/-4rJ pit t INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 171 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 El AGENT Cl SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are t e an accur o the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application be' COM nce with all Pertinent provision of the Massachusetts State bing Code and Chapter 142 of the General Laws. PLUMBERJGASFITT AME: . 0C'et✓ LICENSE 7/ I‘TURE COMPANY ME: i�(J L C e t „f! ADDRESS: CO at`-9 '/ r' � CITY: /Lb/1L1 / f/t STATE 4 ZIP: (.03 1 FAX: TEL: CELL:78/ 3 / a /1 EMAIL: d/' °/�7A ' 7p d 4 4//t 'c c, - MASTER El JOURNEYMAN LP INSTALLER❑ CORPORATION 0# PARTNERSHIP❑# LLC El#