Loading...
HomeMy WebLinkAboutBLDG-22-004408 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 08,2022 PERMIT# BLDG-22-004408 JOBSITE ADDRESS 76 GREAT WESTERN RD OWNER'S NAME VAN SISE JANET L G OWNER ADDRESS 76 GREAT WESTERN RD SOUTH YARMOUTH MA 02664-1311 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 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/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 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. 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 Matthew Hyland LICENSE# 33776 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG] ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#�—� COMPANY NAME: MATTHEW HYLAND ADDRESS. 127 COPELAND ST, CITY BROCKTON STATE MA ZIP 023016958 TEL FAX CELL EMAIL hvlandhvacna,gmail.com S310N MIA NVld #11W213d $:333 ❑ ❑ 111M3c1 3H1 SY S3A 3S NOI1VOIlddV SIH1 oN saA S310N NO1103dSNI 1VNId AINO 3Sfl 80103dSNI 210d 30Vd SIH1 S310N NO1103dSNI SVO H0l021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rT CITY L \,).J z L�t �R 12 11---a uT 1-t MA DATE 2• ?- a a PERMIT# t t Lt //S. JOBSITE ADDRESS 7 Lie.ev,l 0 Q.S -tR-A Rib OWNER'S NAME ,]A11/4.2� V K j,.S c v G OWNER ADDRESS TEL SOS'-WSS O FAX i TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 21' PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: EJ PLANS SUBMITTED: YES❑ NO Igj APPLIANCES 1 FLOORS BSM 1 2 3 4 1 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER MI FRYPL ■ �❑���■�■ FIREPLACE FU R ■�■■�■■■MI FURRNACENACE GENERATOR GRILLE MI ■� ■■■ INFRARED HEATER11 LABORATORY COCKS —____-' MAKEUP AIR UNIT OVEN 5111111.111—�________ POOL HEATER ROOM)SPACE HEATER ROOF TOP UNIT R ' Ci l TEST UNIT HEATER �$ UNVENTED ROOM HEATER WATER HEATER E3 j •OTHER y ENNIllti II UI INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES le NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (r OTHER TYPE 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. CHECK ONE ONLY: OWNER 0 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 ac at the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance I ertinent provision of the Massachusetts State Plumbing Codeo/ and Chapter 142 of the General Laws. / PLUMBER-GASFITTER NAME 1'kt11t Inl lkit/I+i, LICENSE#3/776' / SIGNATURE MP❑ MGF❑ JP RI' JGF❑ LPG!❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# l� COMPA Y NAME '(LAA)� il\(\C , ADDRESS a CJ 1-ell.• _ CITY (ANclt,PI STATE 0 ZIP b 362 TEL FAX CELL 77`�'S61-7(4b EMAIL Fitt/Iih IOC E 641 %L• Cowl _ 1C - IDS CI S (-)_