HomeMy WebLinkAboutBLDG-22-004420 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"F CITY 'YARMOUTH I MA DATE February 08,2022 PERMIT# BLDG-22-004420
r ;
' JOBSITE ADDRESS GRANT RD OWNER'S NAME BILLMAIR STACEY L
G OWNER ADDRESS 9 GRANT RD WEST YARMOUTH MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL Q
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 1
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 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 ❑
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 1 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 Matthew Hyland LICENSE# 33776 SIGNATURE
MP❑MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑#
COMPANY NAME: MATTHEW HYLAND ADDRESS. 127 COPELAND ST,
CITY BROCKTON STATE MA ZIP 023016958 TEL
FAX CELL EMAIL hvlandhvacWamail.com
S310N M3IA32i NVId
# $ :333
❑ 0 111A1d3d 3H1 SV S3Aa3S NOI1VOIlddV SIHL
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S310N NOI103dSNI 1VNId AlN0 3Sl 210133dSNI 2:103 3DVd SIHL S310N N01103dSNI SVD HOf1021
—
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .
' ill k CITY 1f.)Q,ll \Aiaji, ! MA DATE r�" �' PERMIT# 2 Z - 4"1-4
JOBSITE ADDRESS l G'RAAvg h OWNER'S NAME�ic,c P.cA
GOWNER ADDRESS TEL Ca',S ?, - UI LU FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL ❑ RESIDENTIAL[�
PRINT , '
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:Ef PLANS SUBMITTED: YES❑ NO gj
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I
BOOSTER
CONVERSION BURNER ( I
COOK STOVE 1
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR 1
FURNACE _ _
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER R IE C E g v gi
ROOF TOP UNIT
TEST r i, r
UNIT HEATER i
•
BurL EB 0 7 ai12 j
UNVENTED ROOM HEATER i�INGWATER HEATER ,ay tPAH7 TM T
OTHER --`
1
INSURANCE COVERAGE
I have a current Iiability.insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND El
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 El
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 ac at 6 the best of my knowledge
and that all plumbing w rk and installations performed under the permit issued for this application will be in compliance I ertinent provision of the
Massachusetts State Rumbing Code and Chapter 142 of the General Laws. / !/
PLUMBER-GASFITTER NAME iltrIltittn,11 MiL?4a� LICENSE#3377Cv / SIGNATURE
MP❑ ,MGF❑ P 2/ JGF III LPGI III CORPORATION❑# PARTNERSHIP I ❑# LLC❑#
I /
COMPA Y NAME±`I LAttA W.\1f\C , ADDRESS cS a �,de J-�L
CITY ',Anitot,PR STATE A, ZIP b�36 2 TEL
FAX CELL 77`i'ciii-7S 7b EMAIL Iltk,iNE 11V4C, @ umic• CAU.
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