HomeMy WebLinkAboutBLDG-23-001727 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
' ,. r CITY YARMOUTH MA DATE September 30,202 PERMIT# BLDG-23-001727
JOBSITE ADDRESS 25 JO-ANNA DR OWNER'S NAME ron brunell
G OWNER ADDRESS 25 JO-ANNA DR SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 63
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES El 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
GENERATOR 1
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
LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY BOND ❑
OWNERS 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 Moniz LICENSE# 30307 SIGNATURE
MP❑MGF❑JP 0 JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: MARK A MONIZ ADDRESS. 14 KNOLLWOOD DR,
CITY E FALMOUTH STATE MA ZIP 025367225 TEL
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FAX I I CELL EMAIL monizplumbingngcomcast.net
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#lIWH3d $ 333
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r CITY •Flitneoti titx F i. ._..._ MA DATE -30 �` �- PERMIT # 2 / 7 2 7
JOBSITE ADDRESS �- O - Ann ct �✓1� . OWNER'S NAME e: ✓�r � �.
GOWNER ADDRESS I ,� ... _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-* BSM 1 2 3 1 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
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I v NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY v OTHER TYPE INDEMNITY D 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: OWNERl AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of t-ie 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 w" all Pert a,t provisi of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Mark Moniz .7:1LICENSE # 30307 SIGNATURE ..
MP MGFID JP - JGF4 j LPGI CORPORATION -#r PARTNERSHIP # #
COMPANY NAME: Moniz &Son Plumbing_ ADDRESS i14 Knoliwood Dr.
CITY Falmouth ,-
_� STATE MA ZIP 02536 TEL 5 • •C .. .a .
FAX CELL EMAIL monizplumbing@comcast.net -SE/n-7M -
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