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HomeMy WebLinkAboutBLDG-22-005832 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 12,2022 PERMIT# BLDG-22-005832 JOBSITE ADDRESS 3 PUMP HOUSE LN OWNER'S NAME KOWALSKI EDWARD J JR G OWNER ADDRESS PARENTEAU KATHRYN B 3 PUMP HOUSE LANE WEST 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 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 1 OTHER DESCRIPTION:relocate gas main 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 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 Charles Delvecchio LICENSE# 13269 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# 1 COMPANY NAME: CHARLES M DELVECCHIO ADDRESS. PO BOX 719, CITY FORESTDALE STATE MA ZIP 026440702 TEL FAX CELL EMAIL none S310N M31A32i NVId #1IWH3d $:33d ❑ ❑ 111,1213d 3H1 SV S3A213S NOIlVOIldd%SIHI oN saA S31ON N01103dSNI IVNId AINO 3Sfl H0103dSNI HOd 30Vd SIH1 S31ON NO1103dSNI SVO HOl0?J CID - APPLICATION # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK z minim CITY 'A) ` ,----t "4i MA DATE -- 1 1— Z2_ PERMIT # 5 L JOBSITE ADDRESS -j Cuifv t.'iv OWNER'S NAME \,(CAL,f k K. I OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMM• 'CIAL❑ EDUCATIONAL ❑ RESIDENTIALai/ PRINT CLEARLY NEW: ❑ RENOVATION: ri REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑ APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 r 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 ROOM / SPACE HEATER APR 11 2022 1 ROOF TOP UNIT B� I TEST ii� DING EHAP1 F ENT UNIT HEATER aY .:_ 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 El/NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE GE 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 ❑ 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 a ac rats,to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ce h I Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME cm L25 Dy2v, t co )(o LICENSE # 0)1(‘,411 SIGNATURE MP MGF JP JGF LPG! CORPORATION ❑v�# 2055- 1 PARTNERSHIP ❑# LLC ❑# C`l El ❑ ❑ ❑ COMPANY NAME: 0,.N15, -�- 1 Orn A-'6 ADDRESS c-)C CITY I\l4,Sh71 ).' STATE 01 ZIP ? .,L1q TEL L-17 ) — L I k FAX CELL ` C `,122, EMAIL Cciee_ 'Iv ��•(9 CV\` �, ��i 1 �� C, - (c \ . CI� fl bt THIS APPI IC:ATION SFRVFS AS THE PERMIT YFS NO FFF•