Loading...
HomeMy WebLinkAboutBLDG-19-002554 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 414:j VW CITY YARMOUTH MA DATE October 29,20' PERMIT# BLDG-19-002554 G G JOBSITE ADDRESS 73 CAPT WRIGHT RD OWNER'S NAME ST GEORGE MARY BETH TR OWNER ADDRESS THE MARY BETH ST GEORGE FAMILY TRUST 73 CAPT WRIGHT RD TEL SOUTH YARMOUTH MA 02664 . TYPE OR OCCUPANCY TYPE COMMERCIAL❑ /4',�4 4 RESIDENTIAL D PRINT `�� CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:D Il� i/ 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 i COOK STOVE DIRECT VENT HEATER - - DRYER FIREPLACE 1 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 i 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 0 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 Richard Olsen LICENSE# 2116 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION©# 2116 PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS PO Box 2026, CITY Dennis STATE MA ZIP 02638 TEL FAX CELL EMAIL • /l�/(J ago g� rrc • gip MEM ASMINN SJW S31ON M31A321 NVId r a lr 1 #1111133c1 $ :33d �'l.*SWa /a ❑ ❑1IW213d 3Hl SV S3A 3S NOI LVOIlddV SIHl oN saA S31ON NOI103dSNI 1VNId AlNO 3Sl 21O103dSNI 2iOd 3OVd SIHl S31ON NO1103dSNI SVO HOflO2l