HomeMy WebLinkAboutBLDG-20-004550 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
74 CITY Yarmouth MA DATE 2/18/20 PERMIT# G- G' ' 15:
JOBSITE ADDRESS 1 Weld Path OWNER'S NAME Frank Corsi
GOWNER ADDRESS 744 Belmont St Watertown MA TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
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
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 RTMENT
Massachusetts General Laws,and that my signature on this permit application waives this requirement. F3y
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 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 Richard Farrenkopf LICENSE# 33051 SIGNATURE
MP MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME: R Farrenkopf III P+H ADDRESS 41 Riverdale South
CITY South Dennis STATE MA ZIP 02660 TEL 5083603175
FAX CELL EMAIL richardfarrenkopf@yahoo.com
F
k)
b