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HomeMy WebLinkAboutBLDG-22-007362 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 22,2022 PERMIT# BLDG-22-007362 JOBSITE ADDRESS 43 MEDINAH DR OWNERS NAME ALLAN ROBERT J G OWNER ADDRESS C/O WRIGHT JOAN M P 0 BOX 1075 BARNSTABLE MA 02630 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0 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 Richard Augusta LICENSE# 31753 SIGNATURE MP❑MGF 0 JP© JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RICHARD D AUGUSTA ADDRESS. 12 MEADOW VIEW DR, CITY E FALMOUTH STATE MA ZIP 025365241 TEL FAX CELL EMAIL augustaplumbingnagmail.com S31ON M3IA321 NVld _-- #1IW2i3d $ :33d El El i11*13d 3E11 SV S3A213S NOI1VOIlddd SSIR!. ,-i >/ F Z/ 7 Ji oN seA S310N NOI103dSNI 1VNld AlNO 3Sf1210103dSNI 210d 39Vd SIH. S310N N01103dSNI SYJ HJ(1021 • MASSAGIIUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _;= =- J as "' r CITY r �Ov�1` �o r� MA DATE V ac�- PERMIT# JOBSITE ADDRESS 14 / C al n -k ` t D OWNER'S NAME GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL[Pr PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES El NO El APPLIANCES 1 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 RECEIVED ROOM/SPACE HEATER w-� ROOF TOP UNIT TEST JUN 22 2022 1.UNIT HEATER UNVENTED ROOM HEATER BUILDING ULPARTMEn]I WATER HEATER By 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 El 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 n e are true and a c rate to the best e t o s oy ofknowledge and that all plumbing work and installations performed under the permit issued for this applicationwill comhe plia State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ,� �VU 5 t LICENSE# l-15') SIG ATURE MP❑ MGF El JP /�JGF❑ LPG!❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME -Au�c.' '[u r�Ej i� ADDRESS 1 a Alk C0.dbL." Vi t- E CITY • r- �C �• STATE /V`k ZIP O°5 6 TEL ��I►"'`f�V FAX CELL _._J V 1 b' EMAIL /-'A vj i$`k- e G C(1►1 CV 33�