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HomeMy WebLinkAboutBLDG-23-000353 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 14,,,,,,r1 CITY YARMOUTH J MA DATE (July 21,2022 I PERMIT# BLDG-23-000353 JOBSITE ADDRESS 132 HERITAGE DR OWNERS NAME Cheryl Molle G OWNER ADDRESS MA 02025 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 B _ 9 10 11 12 13 14 BOILER BOOSTER • CONVERSION BURNER _ COOK STOVE _ DIRECT VENT HEATER 1 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 Thomas Keir LICENSE# 31092 SIGNATURE MP❑MGF❑JP© JGF❑ LPG!0 CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: THOMAS E KEIR ADDRESS. 123 QUINAQUISSET AVE, CITY IMASHPEE I STATE MA ZIP 026492914 TEL FAX CELL EMAIL tekplumbingandheatingI yahoo.com S310N M3IA321 NYld #tIL J 19d $ :33d ❑ ❑ 1I1%13d 3H1 SY S3A213S NOIIYDIlddV SIHl oN saA S3ION NO1103dSNI lYNId AlNO 3Sfl 210103dSNI 2:1Od 3OVd SIHL S310N N01103dSNI SVD HOf102! c MASS-ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK VV.— CITY r,NI d v -1'k _ MA DATE fv 17 di '4 =)- PERMIT # 23 — O 3 S-3 L 2 kTE ACi)DR SS 3 .d. �c r/Y�. -e- .0t'A OWNER'S NAME C-`ier /e— e6/4._ _..i BUGNG UE OWN ER1 RESS r 4 _-- fikkl, ,..1,4 RITEL f41' < 6-Y— ' FAX k - 4-.-.e- -- ---------- -- R D1,�//1/1.A.---2 /17 a. 0 .A 76 7 PRINT OCCUPANCY TYPE COMMERCIAL ❑ < EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW: 7 RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES n NO n APPLIANCES 1 FLOORS—* _BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER i CONVERSION BURNER COOK STOVE i DIRECT VENT HEATER I 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 } INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES j 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 n AGENT n 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 LICENSE # '$i -"f 2- SIGNATURE MP ❑ MGF ❑ JP JGF LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME _ Dig t" ADDRESS /i/ if wi/ id f/7in CITY yV- D v �� STATE � ZIP 0 ;�,.� ,� Q TEL 7 7 a (573 . it-,,, rg-- V FAX CELL EMAIL1e-k" fIt)ih , Y� • 4J4e&t/jC) l 0o , (v.en