HomeMy WebLinkAboutBLDG-22-002965 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE (November 22,2021 PERMIT# BLDG-22-002965
rn JOBSITE ADDRESS 379 WEIR RD OWNERS NAME KARRAS STEVEN J TRS
G OWNER ADDRESS KARRAS CHERYL A TRS 379 WEIR RD YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: El 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 _
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 1
OTHER DESCRIPTION,underground gas service
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 at 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 at plumbing work and installations performed under the permit issued for this application will be In compliance with as Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME David Roderick LICENSE# 967 SIGNATURE
MP❑MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑#I ILLC❑#
COMPANY NAME: DAVID W RODERICK ADDRESS. 83 CLEARWATER DR,
CITY HARWICH STATE MA ZIP 026452901 TEL
FAX CELL EMAIL russ2ccc(�.9mail.com
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FI T T 1NG WORK
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PERMIT
JOBSITE ADDRESS f. 1 k C•-.) e*C"'' c 1 ~ t OWNER'S NAME J`e" %- c'`cC.' �S
GOWNER ADDRESS . c\�� TEL TIV A-Ct9tk"al‘S c FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ^ RESIDENTIAL -7,_
PRINT
CLEARLY NEW: RENOVATION: 7 REPLACEMENT: PLANS SUBMITTED: YES Li NO 4
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER I
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE ' I 1
FRYOLATOR _
FURNACE _
GENERATOR
GRILLE
I 1
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
_ OVEN
POOL HEATER A i
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST _ 1 & 2021
UNIT HEATER
UNVENTED ROOM HEATER j BUILDING L){J ARTNMENT
WATER HEATER �--"--"_--- -------
OTHER
k e* )(-- \ "k- '
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IX, NO 11
I'IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 7 AGENT 1
SIGNATURE OF OWNER OR AGENT
I hereby certify that ail 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 c n plianc with a rtin t pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - \ )
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PLUMBER-GASFIT ER NAME t\J b \ D E,i\ LICENSE # C\0 SIGNATURE
MP ❑ MGF _ JP _ JGF p II\
LPGI `A, CORPORATION I: # PARTNERSHIP _ # LLC _ #
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