Loading...
HomeMy WebLinkAboutBLDG-22-004418 „� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '”"�pp� CITY YARMOUTH MA DATE February 08,2022 PERMIT# BLDG-22-004418 7 '�-�� JOBSITE ADDRESS 16 MARGARET JOSEPH RD OWNER'S NAME JOLLEY ELLEN M G OWNER ADDRESS 16 MARGARET JOSEPH ROAD YARMOUTH PORT MA 02675 TEL L TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO 0 FIXTURES FLOORS—s BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE 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 OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 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 0 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 at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Matthew Hyland LICENSE# 33776 SIGNATURE MP❑MGF❑JP© JGF 0 LPG( 0 CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: IMATTHEW HYLAND ADDRESS. 127 COPELAND ST, CITY IBROCKTON (STATE MA ZIP 023016958 TEL FAX CELL EMAIL IhvlandhvaG gmail.com I S310N M3IAa1 Ndld #1IINZ13d $ :333 ❑ 0 1111213d 3H1 SV S3AH3S N011V011ddY SIHI oN seA S310N NOI103dSNI 1VNIJ AINO 3Sf1 d0103dSNI 2IOd 39Vd SIHI S310N NOI103dSNI WO HOf108 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .lkWs-•;,-,__-,:.J-. r ((�� •�� CITY L/ AM0,17N i',j Q i MA DATE a PERMIT# Z z_ Li t-i l y JOBSITE ADDRESS I A2 �.rP „l c c 1 Q. OWNER'S NAME `f€/t \,o II P GOWNER ADDRESS TEL 5O - 776 • 9 7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2r PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: K PLANS SUBMITTED: YES E NO Iti APPLIANCES 7 FLOORS BSM 1 2 1 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN , POOL HEATER ROOM/SPACE HEATER r_ _ ROOF TOP UNIT R F C F I V F I ` TEST UNIT HEATER I _ _ g (l,� ZQ2� I UNVENTED ROOM HEATER WATER HEATER OTHER BUIL :ING L PAR'1MENT itar -_ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Kr ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q/ 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 ac at the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance I ertinent provision of the Massachusetts State Plumbing Code/ and Chapter 142 of the General Laws. ,/ o PLUMBER-GASFITTER NAME 1"�At1Knni \1,N41,), LICENSE#337767 ` SIGNATURE c MP❑ MGF❑ JP [( JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# 1 COMPA , Y NAME l {LA/A \\II+1\C , ADDRESS 41 a CJ -P2 J • CITY (ANtt}t,PH STATE AA ZIP OA)2 TEL FAX CELL 774'c6i-7,06 EMAIL il'IC 9Ai 1.1Vg, l". 6I114iC• C°01 C 1-C4 Ices c ca—