HomeMy WebLinkAboutG-19-2288 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• ;Int CITY YARMOUTH MA DATE October 17,20' PERMIT# BLDG-19-002288
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JOBSITE ADDRESS 18 CHANNEL POINT DR OWNER'S NAME BURKE JAMES
G OWNER ADDRESS BURKE PAMELLA P 200 N KING ST NORTHAMPTON MA 01060-1120 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL
PRINT
CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NOD
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 1
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 D OTHER OF INDEMNITY 0 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 Walter Nye LICENSE# MA SIGNATURE
MCI MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: Nye Plumbing 8 Heating ADDRESS 349 Great Westem Road.
CITY Harwich STATE MA ZIP 026733718 TEL
FAX CELL EMAIL
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