HomeMy WebLinkAboutBLDG-22-006827 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE May24,2022 PERMIT# BLDG-22-006827
JOBSITE ADDRESS 145 GREAT WESTERN RD OWNERS NAME SIMONDS RALPH M III TRS
G OWNER ADDRESS SIMONDS FONDA E TRS 145 GREAT WESTERN RD SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El 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
GENERATOR 1
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 I
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 El 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 LESTER WADE LICENSE# 4569 SIGNATURE
MP 0 MGF El JP❑ JGF El LPG! El CORPORATION 0# 1 PARTNERSHIP 0# LLC❑#
COMPANY NAME: LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD,22 CAPTAIN ISIAHS RD
CITY [COTUIT STATE MA ZIP 026352702 TEL
FAX r CELL EMAIL infotyccipoenerators.com
S310N M3IA321 NV-Id
#1IWd3d $ :333
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY u r 1/4-4'1-i'I'4'1 MA DATE N`4-� y PERMIT# -- Z — 7
JOBSRE ADDRESS J V (c-a-f' (A e s +-r, C OWNER'S NAME kit (p '`,vt£ 141s
GOWNER ADDRESS S l CL, t- 0 Vi TEL 111 3 S" 1- /`I S FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY 'NEW:l RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO Q
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 S
FURNACE
GENERATOR
GRILLE •
INFRARED HEATER - •
LABORATORY-COCKS • S
MAKEUP AIR UNIT
OVEN •
POOL HEATER
ROOM J SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER •
OTHER •
INSURANCE COVERAGE
I have a current Ilabilityjnsurance 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 0
OWNER'S INSURANCE WAIVEft:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Genera Laws,and that my signature on this permit application waives this requirement.
• CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNKURE 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 y knowledge
and that all plumbing won<and installations performed under the permit issued for this application will be in compliance all P i on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFI i I tit NAME Lf, -F€v` 14.)(1-d c LICENSE# 4 5tp SI RE
MP❑ MGF i1 JP❑ JGF❑ LPGI 0 CORPORATION D# PARTNERSHIP 0# tic 0#
COMPANY NAME "^f Q_(ct cCu ��c('.�z-¢ t?om...-ex ADDRESS �3 F3nv.;ctfi>r'let get.
CITY tRa.sk.p.c STATE /tM ZIP tr) la41 TEL 50�''4i-�—SS$�i
FAX avkA CELL 50S--150--gg1 a _ EMAIL �"Y\.4(-� •l 5 if'S. Ccn