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HomeMy WebLinkAboutBLDG-18-006309 Sr MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - " 09 e_I CITY YARMOUTH MA DATE May 10, 2018 PERMIT# BLDG 18 0063 1- JOBSITE ADDRESS 1121 GREAT ISLAND RD OWNER'S NAME CHACE BARBARA B TR G OWNER ADDRESS CIO POINT GAMMON 46 ABORN ST 4TH FLR PROVIDENCE RI 02903 TEL_ TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW ❑ RENOVATION:O REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD 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 POOL HEATER 1 . 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 Kesuqs Lopez LICENSE# 16301 SIGNATURE MPLI MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: KESUQS LOPEZ ADDRESS 107 Meetinghouse Rd, CITY Mashpee STATE MA ZIP 026492617 TEL I I FAX CELL EMAIL Ikees(a�evenflowplumbing.solutions 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 S• '6' CITY YarMaid-4\ MA DATE 5/7//8 PERMIT# Bt JOBSITE ADDRESS Pa / 6Ycal' )s/akid OWNERS NAME 1 "14/e-45►' 1 G'se OWNER.ADDRESS /la/ Kea' /Slant/ R0( TEL( )/6-037F X J/y'' TYPENT OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL 1 ' CLEARLY NEW:❑ RENOVATION:90 REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ Nee APPLIANCES T 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 T ' FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS r • MAKEUP AIR UNIT OVEN POOL HEATER ' • ROOM ISPACE HEATER I ROOF TOP UNIT TEST tj\2 //)I „� UNIT HEATER lei UNVENTED ROOM HEATER WATER HEATER - OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES AO ❑ 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 Q 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 compIiapce 'th all Pertine ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 4'5 GAS O f - LICENSE#63c, )' SIGNATURE MP 731 MGF❑ JP ❑ JGF E LPG' ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME iI✓VGA( 1ID W L,i m.loi �^s ADDRESS/0 / CITY I01610 l )�C STATE inA ZIP / TEL 7741/023* / (O FAX i'v/A CELL 'oC -/b 0 EMAILkaS v Doplopt i/i'7j.WO-100 1V 5D T I rf1 FA Ca I 0 FA 1 cif) w.1 I t 1 a Z • FA �O f I Q w C) U Eli j mo t- — - - 1 �r a Ui U Z co Iat z 12 :-.1 a. a_ 1S tij Ui I I I CA Z 0 I f w 1 l I l 24 Mass.gov Licensing and Permitting Portal Page 1 of 1 ;a. State Offices ei Coot is z'sitate oif Topics State Forms Annessibiiitv FAGO .e.s. An Official website of the Commonwealth of Massachusetts •-; :e" elicensing and ePermitting Porta! I Set ister for an AC.CQI.,Ilt I t.Q211 Need Help?For technical assistance in using this web application,please call the °PLACE Help Desk Team at(844)'733-7522 or(844)73-ePLAC between the hours of 7:30 AM-5:00 PM rVionday-Friclay.with the exception of all Commonwealth and Federally observed holidays.If you prefer,you can also e-mail us at °PLACE helggeskOstate.ma us.For assistance with nontechnical issues please contact the issuing Agency directly using the links below Contact Alcoholic Beveraaes Control Commission Contact Division of Capital Asset Managementan.d.Maintenence Contact Department of Labor Standards Contact[Division of Professional Licensure Translation Information-Click t'loio To apply for an Energy and Environmental Affairs(DEP,MDAR or DCRy permit or license,please click here. Poct.tment..ftachrirtept:In order to upload required documents,this system requires Microsoft Silverlight.which can be downloaded for free here,. c.pn.yenience..Egeiplease note there may be a convenience fee for all online credit card transactions.There is no fee for online payment by check Home Manage Licenses,Permits&Certificates File&Track Complaints Please refer to the Licensing Entity's website for ariditiortal information ftgooling the stains and discipitne information thewn below For DPI.information,please visit the 1;2!!„welisitte. Fr ABCC information,pfease visit the Afkii.; Information Pertaining To: Master Plumber 163i icensee Detail License Number: 1630.i. Licensing Entity: Board of state Examiners of Pit.imbers and Gas Fitters License Type: Master Plumber Type Class: M License Issue Date: 01/07/2016 License Expiration Date: 05/01/2020 Status: Current. Current Discipline: Prior Discipline: Name: Kesues Lopez Business Name: DESA Name; „„.. I If Public Documents ©2015 Commonwealth of Massachusetts. Mass Dove Mass Site Policies is a registered service mark of the Commonwealth of Massachusetts. https://elicensing.state.ma.us/CitizenAccess/ SearchaLicense.htm 5/7/2018 tom- J N V W