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HomeMy WebLinkAboutBLDG-22-004406 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE February 08,2022 PERMIT# BLDG-22-004406 JOBSITE ADDRESS 191 OCEAN AVE I OWNER'S NAME CONNELLY PETER F G OWNER ADDRESS 91 OCEAN AVE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL I] RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 1 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 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 at of the details and information 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge and that at 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 Matthew Hyland LICENSE# 133776. I SIGNATURE MP❑MGF 0 JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑#[ ILLC❑#1----1 COMPANY NAME: MATTHEW HYLAND J ADDRESS. 127 COPELAND ST. CITY BROCKTON STATE MA ZIP 1023016958 I TEL FAX 1 I CELL I I EMAIL hvlandhvac(a.gmail.com Y S310N M3IA H NVld #±IW2i3d $ :333 ❑ ❑ 11141a3d 3H1 SV S3AN2S N011VOIlddV SIHl oN seA S31ON NO1103dSNI 1VNI3 AlNO 3Sfl alLO3dSNI HO 13JVd SIHI S31ON NO1103dSNI SY°HOflO I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' 2 `01(.)C $� CITY Sn�1'K h2,v+n�r!-1 MA DATE a- /- a � PERMIT# JOBSITE ADDRESS 5/ OC P.ct vI v-Q OWNER'S NAME 06 C GOWNER ADDRESS TEL-2 7(t• a 6 '0) f j FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL rg PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:i] PLANS SUBMITTED: YES❑ NO gj 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 UNITffri—cE F D OVEN POOL HEATER r ROOM/SPACE HEATER FEB 07�11 ROOF TOP UNIT E TEST BUIL�ING utNH{�7' AIT y._ UNIT 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 E'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 ❑ 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 Codeo and Chapter 142 of the General Laws./ PLUMBER-GASFITTER NAME 1'lRC(H(Inl 11,itA,J, LICENSE#33776' l SIGNATURE MP❑ MGF❑ JP[R' JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPAl YNAME l LAIJ� `�`lC , ADDRESS <la CJJ CITY (AA1tQLPR STATE A ZIP 2 TEL FAX CELL 77q"s61-7 6 EMAIL YL��uS 1-1 C, E Co oft