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HomeMy WebLinkAboutBLDG-19-002037 c,I-d kr ,meg (9/1-5-044"-??Ca) MASSACHUSETTS UNIF9 rAPPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'r CITY IYARMOUTH // I MA DATE October 05,20' PERMIT# BLDG-19-002037 _ JOBSITE ADDRESS 105 FREEBOARD LN OWNER'S NAME KUCK GARY W G OWNER ADDRESS KUCK KATHY J 105 FREEBOARD LN YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRLNT 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 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER • DRYER N FIREPLACE 1 FRYOLATOR FURNACE yOKI t GENERATOR GR INFRARED HEATER /I 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 Stephen Roberts LICENSE# 5104 SIGNATURE MPO MGF❑JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#f COMPANY NAME: STEPHEN W ROBERTS ADDRESS 17 LAKE DR; CITY PLYMOUTH STATE MA ZIP 023605647 TEL FAX CELL EMAIL (� • • 3112e/ flan gl/Pc yrs ( 494V 8310N M31A32! NVld #111N213d $:334 ❑ ❑111N213d 3H1SV S3MJ3S NOI1V3IlddV SIH1 oN saA S31ON NOI103dSNI lVNI4 AlNO 3Sf1 21O103dSNI 2JOd 30Vd SII-IL S31ON NO1103dSNI SVO HOfiO2i