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HomeMy WebLinkAboutBLDG-22-005985 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '° BLDG-22-005985 CITY YARMOUTH _I MA DATE April 19,2022 PERMIT# 4-771 JOBSITE ADDRESS 32 FOREST GATE VILLAGE —I OWNER'S NAME Terrence Milka G OWNER ADDRESS 32 FOREST GATE YARMOUTH PORT MA 02675-1459 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ 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 _ 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 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 pljmbing 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP 026735706 TEL FAX 7 CELL EMAIL haIloilcompanv(a.gmail.com S310N M3IA321 NVId #1IW213d $:333 ❑ ❑ 111VN3d 3H1 SV SINdSS NOI1VOIlddV SIH1 oN sa,A S310N NO1103dSNI lVNId AINO 3Sfl N0103dSNI 210d 3OVd SIHI S310N N01103dSNI SVO HJl021 i ,�/ C: MASSA :HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORT cr?- MA DATE f7///3�Z PERMIT# JOSSiTE ADDI; ESS '1? F 7 ReS . 6.� -OWNER'S NAME /13R •' /C(,IA (4. OWNER ADDR SS TYPE OR TEL 3 } S %`1 S FAX PRINT OCCUPANCY 1 'PE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY ,- NEW: ` R OVATION: REPLACEMENT: PLANS SUBmiTTED: YES ; N AAPPPLIANCES I FLOORS—. RNf i 2 { 3 4 g 6 BOOSTERILER 1 _��1�_� 12 , 13 CONVERSION BURNER - COOK STOVE tECT VENT IiEfiTFR �_�� �= I i DRYER 11111 =__ ' FIREPLACE 4 _�' llillIMININ FRYOLATOR .-i- _I .. IIIIIIMIIIIVIIIIIIIIIIIMIIMIIIINIIIIM FURNACE GENERATOR _� I 4 1 GRILLE INFRARED HEATER ��� ��• i IIIIIIIIIIIIIIIMNNINI LABORATORY COCKS �_��__INIIMINI� == - MAhEUP AIR UNIT , OVEN POOL HEATER _�® I ROOM!SPACE HEATER ��ROOF ' IIIIIIIII I ®� TEST TOP UNIT -�® a� MINI rrIIMINIIIIIII UNIT HEATER UNVENTED ROOM HEATER 4 a� � ( �_�® VVATER HEATER - . OTHER 1111111111111111111111111 NM 1 INSURANCE COVERAGE I have a current liability insuranc policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES t/NO I IF YOU CHECKED YES,PLEASE IN ICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY 4SURANCE POLICY V OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,an that my signature on this permit application waives this requirement. . SIGNATURE OF C NNER OR AGENT CHECK ONE 0, : OWNER AGENT I hereby certify that all of the details; Id Me-nation i have submitted or ; and that all plurrhInp work and instal trona perforated unoer u� issued entered regarding this aeon are.. .: -_ - .. of my of the Massachusetts State Pk a ibing Code andpermit[sued for this application will be In • pltan -8_, ,_ . Chapter 142 of the Gener2i Laws. ,.i „•-" of the i PLUMB ER-GRSFIl ER NAME AN IItN F.EICy�ON �i LICENSE# 1E13U-M , SIGNATURE MP / MGF JP JGF LPGI CORPORATION , z m 3734C PARTNERSHIP # LLC COMPANY NAME HALL OIL COME WY INC. ADDRESS 435 RT 134 CITY SOUTH DENNIS FAX 50&•384,3068 CELL STATE MA ZIP 02660 TEL 5Q8-39B-3831 EMAIL. ialicitompanyggmalcom