Loading...
HomeMy WebLinkAboutG-19-2188 aP MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK in CITY YARMOUTH MA DATE October 12,201PERMIT# BLDG-19-002188 IL, JOBSITE ADDRESS 20 LONGFELLOW DR OWNER'S NAME PERRY ARNOLD J JR G OWNER ADDRESS PERRY KIM L 224 CARROLL ST NEW BEDFORD MA 02740 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO© FIXTURES FLOORS—r 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 1 FRYOLATOR FURNACE ACE 1 GENERATOR ://\) GRILLE P / • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN • POOL HEATER ROOM/SPACE HEATER o ROOF TOP UNIT TEST / / UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION:gas fireplace Insert 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❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS 110 Breeds Hill Rd, Unit 5, CITY Hyannis STATE MA ZIP 02601 TEL FAX CELL EMAIL • a fio/77 -/-)n _fin ow aro;--2/ , -//(4/fri no �l� no 8310N M31A32i NVId #111n1H3d $:33 J ❑ ❑11W2i3d 3111 SV S3ML13S NOIIVOIlddV SIH1 ON SeA 8310N NO1103dSNI 1VNId ,LINO 3S112i0103dSNI 80d 30Vd SIHI S310N NO1103dSNI SVO HOf1OU •