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Home My WebLink AboutBLDG-22-002899 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [(ARMOUTH J MA DATE November 18,202' PERMIT# BLDG-22-002899 JOBSITE ADDRESS 34 WILLIAMS RD OWNER'S NAME Jessica Bassett G OWNER ADDRESS 34 WILLIAMS RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ 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 1 DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE 1 GENERATOR 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 ❑ 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 tie details and information I have submitted or entered'egarding 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 Gray LICENSE# 34752 SIGNATURE MP❑ MGF ❑ JP El JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: COUNTRY WAYS P&H ADDRESS. 1197 Tremont St, CITY Duxbury STATE MA ZIP 02332 TEL FAX ]CELL EMAIL matthewdray77(cigmail.com S310N M31A3HJ NVId #1I01213d $:33d ❑ ❑ 111Al213d 3H1 SV S3ALOS NOI±VOIlddV SI1-11 oN S S3lON N01103dSNI 1VNId AINO 3Sfl N0103dSNI 210d 3OVd SIHl S310N NOI103dSNI SVO HOfOH MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: �.*LCMOV 2 V 1$45 . __ MA DATE: PERMtT# t) JOBSITEADDRESS: 3'1 4),I.``tcat& �`l1. OWNER'S NAME TO- 1TceS(tLl gasse11 � o G9 OWNER ADDRESS: TEL: FAX: es TYPE NOR OCCUPANCY TYPE COMMEf3CIAL 0 EDUCATIONAL ❑ RESIDENTIAL B`'RI CLEARLY NEW:0 RENOVATION:Q REPLACEMENT:❑ PLANS SUBMI I I hD: YES❑ NO E APPLIANCES? FLOOR-' Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1� BOILER BOOSTER CONVERSION BURNER � .. COOK STOVE I v DIRECT VENT HEATER DRYER A ,'—� czs FRYOLATOR FURNACE I 4 GENERATOR L GRILLE VI INFRARED HEAItit LABORATORY COCK l 1'. ',N P r MAKEUP AIR UNIT }'`a E� -s.. OVEN I I cJ POOL HEATER i I NI/ 1 I Z� ; ROOM/SPACE HEATER i -J ROOF TOP UNIT 1—-_ ._ ---, TEST U'._'1 L D I pi - _ -';i,�r aA E D11. UNIT HEATER ' . _______�;e.=__-__ 1 m lj UNVENTED ROOM HEATER ' WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0 If you have checked YES,please indicate the type of coverage t y checking the appropriate box below. LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY El 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 hereby certify that all of the details and information!have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing worts and installations performed under the permit issued for this application will p4 all Pertinent provision of the Massachusetts Statee.Plumbing Code and Chapter 142 of the General Laws.}aw PLUMBERIGASFI1TER NAME: 16 6` LICENSE#3�7 sa S V ul1 SIGNA COMPANY NAME: l O1kA r1 u,(,l. S P {- II-Pl }t al ADDRESS: II�7 I r-ciln cm.-I- S-t I CITY: 1)tr -V IN-1.1 STATE: /`l/l ZIP: 0 3 3) FAX: TEL: -6 I-S$9 i63a ELL: 5 --.— EMAIL: fr I ki.t,J 6cc i -27& Mu, I. C°",-, MASTER❑ JOURNEYMAN Er LP INSTALLER❑ CORPORATION❑# PARTNERSHIP 0# LLC 0# c hmi c. ADZ e Ss 1,,.`