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HomeMy WebLinkAboutBLDG-22-005002 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 1,aa CITY EARMOUTH MA DATE March 10,2022 PERMIT# BLDG-22-005002 JOBSITE ADDRESS 2 COUNTRY CLUB DR —1 OWNER'S NAME Jennifer Pope G OWNER ADDRESS 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 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 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 ICARL RIEDELL 'LICENSE# 18246 1 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ICARL S RIEDELL I ADDRESS. 778 MAIN ST, CITY IOSTERVILLE I STATE MA ZIP 1026552011 I TEL FAX 1 —1 CELL 1 I EMAIL 1 S31ON M31A321 NVId #11W2J3d $:33d ❑ ❑ 1I1,4213d 3H1 SV S3A213S NOILVOIlddV SIH1 oN se,) S310N NO1103dSN11VNId VINO 3Sl 210103dSNI 210d 3JVd SI1-11 S310N NO1103dSNl SVO H000d — i_, L... ____ \ , „).,... C. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK iitfl. t;cA e Y 2_, - CITY 1 lif---MitT11--.-- , ; MA DATE • PERMIT # SUO 2 41. , ___...........A .....- JOBSITE ADDRESS- WNERIS NAME _ya- p6_ .. . ..... . G OWNER ADDRESS afx 520.42,22.06 ,,,,,, _..,.....,,,„1 TEL . . • AX I TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL i RESIDENTIAL ' 3 CLEARLY NEW: 71 RENOVATION J : ,.. REPLACEMENT: PLANS SUBMITTED. YES ___ APPLIANCES -1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 '14 BOILER BOOSTER _,... , inglinWitMEWIL ,111.MIIIPMNIMINIIIII. CONVERSION BURNER impnsusamminimmiumni ! COOK STOVE WHINIMINNIMINERINKIIIIIIIIIIIIIMMINt : DIRECT VENT HEATER INEMISEMMINE11111111,1:77111110. - 117-1r----liiiMir; DRYER 111111111MOINIIIMMIF-7,-1111111111: .1! , FIREPLACE ME MINIMMENnimounall s; AMMINIIi ]i : FRYOLATOR INKINIMIMIIIIMINIFTi 1--- FURNACE 1 11111011101 GENERATOR GRILLE wit sminimmir......7[ , , ! INFRARED HEATER ....______— 111.111KAIIII-1 1111011MIIIIIMME: LABORATORY COCKS IIIK II 1 i; :111111111.1 ' MAKEUP AIR UNIT 4, "-- . .... OVEN ,. , - . _ . . POOL HEATER . ROOM / SPACE HEATER 1 ,. ___. . , —, ' . : ROOF TOP UNIT F ' : I • TEST Mt ,. . . : . UNIT HEATER ._„. ,„ . . . . ,_,... UNVENTED ROOM HEATER 1. WATER HEATER _. ... ___ OTHER : : — ....2.1.,..04.14....:4........ .........0..iiii4tai.................owstelitomieV.x..S;05.....: ' .•••...........*:,,...xwaN e.r...=...*ex.r•eowc .... winern,..x.easay.win r___ .wip.../.........*....row- . , . ' INIIIIMMININE : um .,..... . . . . -......- . ....„,,„, 5. ' _......,..._____1._ .:. .---— ---.7 I '' I INSURANCE COVERAGEI 7— - - I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IX NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -.. LIABILITY INSURANCE POLICY ;,)(.. OTHER TYPE INDEMNITY r i BOND Li 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 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 complia , sith all PrAept provi510114the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ------------ -.....-----------------i PLUMBER-GASFITTER NAME C_ c.-,-. ( I -c.. - r.; , f ci.i c: i t 1 LICENSE ft, en:,,y6 : s -NATURE - f.. , MP F. ', MGF Ei JP JGF i i LPGI ! 1 ',-ORPORATION ' 4 '. PARTNERSHIP! . ;#,' LLC 1#i ,....,.. ,...,...,,.. .—..:,; _ __________, , COMPANY NAME:I /- ,--- i I 1- 17) ,.= ii ,,, 1 1 r , n ADDRESS - -7 1."--1 c.. 1 n 7-) Vcele -.4 -----------,----.. ----; r______ — _ , I -- - ;,- CITY , L_,) ,D I 1 \ C. ij..,,,:).. .':.z. - .67.. j .... ---:. ........, .i lEMAILI I FAX l I Hai I — I