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HomeMy WebLinkAboutG-19-1084 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I "h CITY YARMOUTH MA DATE August 22,2011 PERMIT# BLDG-19-001084 JOBSITE ADDRESS 18 MYRTLE LN OWNERS NAME (BANKS CAROLYN E G OWNER ADDRESS 208 CARLSON LN W BARNSTABLE MA 02668 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ • PLANS SUBMITTED:YES❑ NOD FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 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 0 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 Kevin Saunders LICENSE# 4546 SIGNATURE MPD MGE0 JP❑ JGF❑ LPG!El CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: KEVIN C SAUNDERS ADDRESS 67 HELMSMAN DR, CITY YARMOUTH PORT STATE MA ZIP 026752467 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE Yes No THIS APPLICATION SERVES AS THE PERMIT❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r