HomeMy WebLinkAboutBLDG-23-004553 ..,\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
7�e CITY 'YARMOUTH MA DATE 'February 15,2023'PERMIT# BLDG-23-004553
JOBSITE ADDRESS 18 MEADOWBROOK RD I OWNER'S NAME IGREENE WILLIAM A JR
G OWNER ADDRESS IGREENE CHRISTINE L 25 MICHELLES PATH WEST YARMOUTH MA 02673 TEL I I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES El NO El
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 _ 1
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 El NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY❑ BOND El
OWNERS 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 (Stephen Roberts 'LICENSE# 15105 I SIGNATURE
MP El MGF El JP El JGE El LPGI El CORPORATION El#I I PARTNERSHIP El#I 'LTC El#
COMPANY NAME I ADDRESS. 117 lake dr.
CITY Plymouth STATE 'MA I ZIP 1023600000 I TEL
FAX CELL 15086480900 I EMAIL
q /2q
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
a r.b CITY YARMOUTH 1. MA DATE February 15, 2023 PERMIT# BLDG-23-004553
JOBSITE ADDRESS OWNER'S NAME KATHLEEN ANN WELSH
G OWNER ADDRESS IMICHELE J ROURKE 26 ST ANDREWS WAY SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL. ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ 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 1
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 ❑ 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 :he 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 -egarding 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 Stephen Roberts LICENSE # 5105 SIGNATURE
MP ❑ MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME: ADDRESS. 17 lake dr,
CITY Plymouth STATE MA ZIP 023600000 TEL
FAX : CELL 5086480900 EMAIL
pk_ 2117//2 3 cf s