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HomeMy WebLinkAboutBLDG-23-001430 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kl-lri4 CITY YARMOUTH MA DATE September 19,202 PERMIT# BLDG-23-001430 ° JOBSITE ADDRESS 28 PROSPECT AVE OWNER'S NAME Joe Manqiaratti G OWNER ADDRESS 28 PROSPECT AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 Jan Kvietok LICENSE# 33892 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: TATRA BUILDING CO.INC. ADDRESS. 755 Rte 28 Suite H, CITY West Dennis STATE Ma ZIP 02670 TEL FAX CELL EMAIL infona.tatraco.com S3 LON M9IA3a NVId #11101213d $:33d ❑ ❑ 1IV d d 3Hl SV S3Aii3S NOIlv3llddV SIHl oN se), S310N NO1103dSNI 1VNId AINO 3Sl 210103dSNI 210d 39Vd SIH1 S310N NO1103dSNI SVD HOf10N or. . r--- 2 `—`. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK !'4.7i* E [ly EalrloJthlz dpMA DATE 9/6/2022 PERMIT # Z3 `+ 36 1 �J��E A)DRESS 28 Prospect Ave OWNERS NAME Joe Mangiaratti OWNER ADDR ASS 28 Prospect Ave TEL FAX Etliiriil hi DE PARTMENT B - - OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW: El RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES ® NO ❑ APPLIANCES -1 FLOORS-- KM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST fUNIT HEATER 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 X❑ 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 ❑ 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 El 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 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 complianc with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �t_rt 1 -- PLUMBER-GASFITTER NAME Jan Kvietok LICENSE #16783 SIGNATURE MP ® MGF El JP El JGF ❑ LPGI ❑ CORPORATION ® # 3607 PARTNERSHIP El # LLC ❑ # COMPANY NAME Tatra Building Company Inc. ADDRESS 1268 Route 28 CITY South Yarmouth STATE MA ZIP 02664 TEL 774-317-0593 774-317-0593 office(c�tatraco.com FAX CELL EMAIL —