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HomeMy WebLinkAboutBLDG-17-004569 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 6 CITY YARMOUTH MA DATE March 09, 2017 PERMIT# BLDG-17-004569 fl "., JOBSITE ADDRESS 205 SOUTH ST OWNER'S NAME RANTA ASHLEY EMMA G OWNER ADDRESS HOYLE JUDY 94 HIGH ST UNIT 2 CHARLESTOWN MA 02129 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 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❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ALEX B BRAGA ADDRESS 2 MOUNTWOOD RD, CITY MARSTONS MLS STATE MA ZIP 026482111 TEL FAX CELL_ EMAIL S1ON M3IA3H NV1d #JIW2i3d $ 33d ❑ ❑lIMad 3Hl SV S3/Vi3S NOIIVOIlddV SIR! oN saA S31ON NO11O3dSNI 1VNId )LINO 3Sfl 2lO133dSNI 2iOd 3OVd SIH± S31ON NO11O3dSNI SVO HOflOm