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HomeMy WebLinkAboutBLDG-22-001610 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE September 21,202 PERMIT# BLDG-22-001610 JOBSITE ADDRESS 33 CREST CIR OWNER'S NAME David Palmer G OWNER ADDRESS MA 02401-5862 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 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 2 FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 2 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 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 Edward Mathews LICENSE# 15180 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: EDWARD J MATHEWS ADDRESS. 24 WOODCREST DR, CITY MELROSE STATE MA ZIP 021763414 TEL FAX CELL EMAIL ed_matthews9ta7.hotmail.com S31ON M3IA321 NVId #11Wi13d $ 33d ❑ ❑ 1111213d 3H1 SV S3/ 13S NOI1VOIlddV SIH1 oN saA S310N NO1103dSNI 1VNl3 AlNO 3Sfl N0103dSNI dOd 30Vd SIHI S310N NO1103dSNI SVO HJIION MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'S *,=r' S ta_, CITY: V G ( M U V MA. DATE: Q I t / '- .\ , PERMIT# 2.1 -!1,10 JOBSITE ADDRESS: 3 3 (.( p S Cl‘ OWNER'S NAME V�I M E• --� G ONNERADDRESS: TEL: FAX: QTYPEOROCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL CIRESIDENTIAL❑PRINT CLEARLY NEW:VI RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ '\ APPLIANCES-1 FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 j BOILER (Jr. BOOSTER CONVERSION BURNER -'A- COOK STOVE 5 DIRECT VENT HEATER DRYER FIREPLACE , --% FRYOLATOR h: FURNACE _ GENERATOR _ GRILLE VI INFRARED HEATER eilj LABORATORY COCK ti , MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER N1 ROOF TOP UNIT ' TEST :Z UNIT HEATER i.V UNVENTED ROOM HEATER WATER HEATER rwL- skir1" ,2 ,t r3rrhQC v� INSURANCE COVERAGE I have a current liabilitLinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0 If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 17' OTHER TYPE INDEMNITY ❑ 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. CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of'he details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all p umbing work and installations performed under the permit issued for this application will be I •compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME FA 'v n`c�k21� c LICENSE# ' S f SIG TURE COMPANY NAME: /'A-I•l c tr-S er Or;- pI✓M ' ADDRESS: 4-1 t''-to L2dC c-2(* CITY: /" 'Q 1' 4 STATE: tAA a ZIP: 0-/ 7 L' FAX TEL: CELL: EMAIL: MASTER 0 JOURNEYMAN 0 LP INSTALLER❑ CORPORATION 0# PARTNERSHIP 0# LLC 0#