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HomeMy WebLinkAboutBLDG-22-001445 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK El ,=f` CITY YARMOUTHkg MA DATE September 13,202 PERMIT# BLDG 22 001445 JOBSITE ADDRESS 6 ELLIS CIR OWNER'S NAME Richard Kaiser G OWNER ADDRESS 20 ELLIS CIR YARMOUTH PORT MA 02675-1335 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ 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 1 FRYOLATOR , FURNACE 1 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 1 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 Mark Watson LICENSE# 3842 SIGNATURE MP❑ MGF © JP 0 JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: MARK D WATSON ADDRESS. 81 CAPTAIN PERRY RD, CITY BREWSTER STATE MA ZIP 026312559 TEL FAX CELL EMAIL pieman83(a�comcast.net S310N M3IA3a NVId #lIWH3d $ 33d ❑ ❑ .UV d 3H1 SV S3A2J3S NOI1V0IlddV SIH1 oN saA S310N N01103dSNMVNId AlN0 3Sfl N0103dSNI HOd 3OVd SIH1 S310N N01103dSNI SVO HOfOa MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r _(' kilik, ' _ . CITY )/(1('M()`. Ve)(2-A MA DATE C) I ? 1 PERMIT# JOBSITE ADDRESS 67 L_L 15 Cl'C1 P OWNER'S NAME fCfr eck IS V\i S C'r GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�--""..-- PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE t DIRECT VENT HEATER DRYER FIREPLACE I FRYOLATOR - FURNACE I ! rz r c, k ti v Ei D GENERATOR a t)cSi&C I ` GRILLE s '+ 3 r i 2�2� INFRARED HEATER I SrE LABORATORY COCKS _ ! (?' i MAKEUP AIR UNIT ' F�U LGIN', L;,1—,iN. ^wi'' OVEN 1 `.` r= -- POOL HEATER ROOM I 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 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW 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 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 grate o the . A ge and that all plumbing work and installations performed under the permit issued for this application will be in com 'th al i— to Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 - 1 , PLUMBER-GASFITTER ME NI AR< 0 )AIS O LICENSE#3gj 91 SIG NATURE MP 0 MGF JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME ►"I M \<S tib1n E_ Se Q\l (ADDRESS 81 CAP ‘ Perry R 0 CITY a 49 3 S- r STATE M V\ ZIP 0 2.46 a 1 TEL ©V . gqb 6ct35- FAX CELL 77Y 2 1 t 1 v I ( EMAIL p e cw 83 0 Cowl (qc1N, r I _ 1. • . 1 0 • 5