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HomeMy WebLinkAboutBLDG-22-004679 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '�' �` r. BLDG-22-004679 CITY YARMOUTH MA DATE February 24,2022 PERMIT# JOBSITE ADDRESS 11 CADET LN OWNER'S NAME Jack Colantonio G OWNER ADDRESS 11 CADET LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED:YES ❑ NO 0 FIXTURES FLOORS-I 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 ,FIREPLACE FRYOLATOR FURNACE 1 GENERATOR 1 _ 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 0 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 Anson Celin LICENSE# 32655 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# Lc ❑# COMPANY NAME: ANSON CELIN ADDRESS. 26 Capt.Blount Rd, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL ansoncelinAyahoo.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES 1 g0. Oo • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY VAMpir tfanMI GLA MA DATE 1---2-22ZPERMIT# 21— LI 6-79 JOBSITE ADDRESS 11 'L f1 OWNERS NAME COC oca OWNER ADDRESS 1 1 ((ADO- Lc TEL 5, t{(r)-?4Iy FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er PRINT CLEARLY NEW:❑ RENOVATION:V REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS—F BSM 1 2 3 1 5 6 7 8 9 10 11 12 13 14 BOILER •BOOSTER j CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER ' _ I •DRYER FIREPLACE ' _ I FRYOLATOR FURNACE GENERATOR _ GRILLE 'INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN J� POOL HEATER • ROOM 1 SPACE HEATER ROOF TOP UNIT TEST . . - -1- . . . . ._ • UNIT HEATER UNVENTED ROOM HEATER WATER HEATER j OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch,142 YES VNO ❑ 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 ❑ 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 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 compile a with all Pertinent provision of the . Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Li PLUMBER-GASFITTER NAME LICENSE#3 24 sS SIG ATURE MP❑ MGF❑ JP"JGF❑ LPGI Cl CORPORATION❑# PARTNERSHIP❑# LLC❑#COMPANY NAME CC h (Pi C4/rt.1r,i,•yyj i--f-I e ADDRESS 24 (' 121oUri-1- CITY .1 Gcr{W7�• STATE M A- ZIP c24 LI' TEL S'&ZZ-1 U-Z.(rf(Z FAX CELL EMAIL Ar15)6.--x(eI it CiG goo,. C cirki