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HomeMy WebLinkAboutBLDG-17-004905 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _(6 CITY YARMOUTH MA DATE March 28, 2017 PERMIT# BLDG-17-004905 JOBSITE ADDRESS 367 ROUTE 28 OWNER'S NAME CAPE COD CHILD DEVELOPMENT PRO G OWNER ADDRESS 83 PEARL STREET HYANNIS MA 02601 TEL TYPE I'E 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 DIRECT VENT HEATER DRYER 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 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 © NOD 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 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 Alex Braga LICENSE# 15668 SIGNATURE MP© MGF❑ JP❑ JGFE LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ALEX B BRAGA ADDRESS 2 MOUNTWOOD RD, CITY MARSTONS MLS STATE MA ZIP 026482111 TEL FAX CELL EMAIL SDlON M3IA H NV-ld •- #1I1AlZld $ 33d f/U/7 4' 2 C/j,h/, 01I01H3d 3H1 SV S3AH3S NOIlV011ddV SIHl oN saA S31ON NOLLO3dSNI 1VNId KINO 3Sfl ?dOlDddSNI elOd 3OVd SIHl S31ON NOI103dSNI SVO HOfOeI