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HomeMy WebLinkAboutBLDG-22-005776 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e CITY YARMOUTH MA DATE April 11,2022 PERMIT# BLDG-22-005776 If '� JOBSITE ADDRESS 34 HIALEAH AVE OWNERS NAME Grace Volpes G OWNER ADDRESS 34 HIALEAH AVE WEST YARMOUTH MA 02673 TEL J TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ 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 1 _ 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 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 'Zachary Lucas I LICENSE# 16865 SIGNATURE MP©MGF❑JP❑ JGF 0 LPG( CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IMID CAPE MECHANICAL I ADDRESS, 300 Queeen Anne Rd.. CITY 'Harwich I STATE MA ZIP 02645 TEL FAX I I CELL EMAIL ImidcapemechanicahW.nmail.com S310N M3IA3b Ndld #lIIN i3d $:33d ❑ ❑ 1111213d 3H1 St/S3A213S NOIIVOIlddV SIHJ oN s8A S310N NOI103dSNI lYNId AlNO 3Sfl O103dSNI 210d 30Vd SIH1 S310N NOI103dSNI SVO HOf102' ___ 5-o.a ...., _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - .4r,*- - ---:- OTT t/aV'y1Uc1 '4 h DATE _II ii_2_____ PERMIT f; 2 2- "7 c APR 0 8 2' bB9TE ADDRESS 31 lJ jq � te0ti ilue OWNER'S NAME C ram (ie tp_s_ ©B iLDtlEE PAr-�AX' C?ADDRESS 3y ti A1p1i4 /�c TEL FAX PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: �/ �1 REPLACEMENT: D PLANS SUBMITTED: YES 0 NO Q- APPLI.ANCES 1 FLOORS-+ 6SIM 1 2 3 1 5 6 7 BOILER9 10 11 12 13 1F BOOSTER CONVERSION BURNER COOK STOVE —r- DIRECT VENT HEATER --`— DRYER 1 — FIREPLACE 1 —'�'— FRYOLATOR FURNACE �— GENERATOR �``— GRILLE INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT • OVEN - POOL HEATER - _ j • ROOM I SPACE HEATER —�_ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER . WATER HEATER OTHERT�- ______ ., i ___,____L______ INSURANCE E I have a current liabiti insurance policy or its substantial equivalent n which meetsthe requirements of MGL.Ch.142 YES [ip I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 0 LIABILITY INSURANCE POLICY [ ' OTHER TYPE INDEMNITY 0 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 pennit application waives this requirement, CHECK ONE ONLY: OWNER ❑ AGENT 0 . 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 Pe ' enl provision of the , 1 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L . PLUMBER-GASFITTER NAME Za-C-LC,..y 1,v csts LICENSE# 16 S r1 SIGNATURE MP Ev MGF❑ JP ❑ JGF❑ LPG' l❑ CORPORATION 0# PARTNERSHIP❑# LLC 0# COMPANY NAME Me\� (-407 (' eidia '1r2'.4 I ADDRESS r° 13 We- /13-1) CITY Lt.). Lk kt' c "I STATE PIA ZIP 02(o G S TEL J bS 2`16 qZ 77 FAX CELL EMAIL PlitA C. p?f1-Le. Rl'1,Z4, (Ci H-A.Ce(I), 69x, 1 1 G;t H 0 Z 1 1 C): 1 H cr1 i 1 0-1 ( 1 J i 1 l t i cbn C 'n i c ' 64 (4r.^ L 1 L i Gx1 x h' 1 ram, a w IT: — L Q Cr) < r.q C.., 17 1L < U� co1..t.E 1 E LI_ I , r, r_ I I C) 1 +-I I 1 0 1 Cro' 1 rAo 0 a i