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HomeMy WebLinkAboutbldg-22-006060 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r" f CITY YARMOUTH MA DATE April 21,2022 PERMIT# BLDG-22-006060 t JOBSITE ADDRESS 14 KEARSARGE RD OWNER'S NAME RED JACKET BEACH LTD PARTNER G OWNER ADDRESS 20 N MAIN ST SOUTH YARMOUTH MA 02664-3150 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: m 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 LABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY BOND ❑ OWNER'S INSURANCE WAIVER:I ant 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 Herbert Healis LICENSE# 20177 SIGNATURE MP❑MGF❑JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: HERBERT M HEALIS ADDRESS. 78 STUDLEY RD, CITY S YARMOUTH STATE MA ZIP 026642906 TEL FAX CELL I I EMAIL hhealis(a)yahoo.com S310N M3IA31:1 NV1d #11 Wa3d $:333 ❑ ❑ 1II41213d 314.1.SV S3Aa3S NOI1d01lddV SIHI oN seA S31ON NOI103dSNI 1VNId AlNO 3Sfl 0103dSNI 2103 3OVd SIHI S310N NOI103dSNI SVO HOf102! MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK y CITYU•h MA DATE 4/21/22 PERMIT# rAPR 40BSL1iEADDRESs 14Kearsage Rd. OWNER'S NAME Ryalls �ttToilv� ATTE s same TEL FAX OR OCCUPAN PE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ® RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 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 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liabiliyinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES ® 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 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. L/_ L 1/L _ /�. PLUMBER-GASFITTER NAME Herb Healis LICENSE#20177 f�Y[�t aSIIG�NATUURREa MP❑ MGF❑ JP® JGF ❑ LPG' ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME __ ADDRESS 78 StudleyRd CITY S. Yarmouth STATE Ma zip 02664 TEL 508 776 5495 FAX CELL EMAIL hhealis@yahoo.com 5-10M1P-•7t."q•?'''117,0",.50,4te.. 2-.•-Att, -.t;-:.-.5.;;;;-,t1.,•-••••• ,..--....:7,;-...-:..,••• -• 7,7•''''''''""'"''''''"'""!'"''''''"''''`"----'•--'"''''''7a-•-'- -----..•••-•-:'-•-•••,,t'--7.. 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