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HomeMy WebLinkAboutBLDG-20-001171 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -- '' . )4 CITY YARMOUTH MA DATE September 03,201 PERMIT# BLDG-20-001171 JOBSITE ADDRESS 5-5A&5B MANOR PATH OWNER'S NAME CLIFFORD DESMOND P G OWNER ADDRESS CLIFFORD DEIRDRE M 14 MERRYMOUNT RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO Erl FIXTURES FLOORS--• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 2 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 © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY❑ 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 Scott Reid LICENSE# 16354 SIGNATURE MP© MGF 0 JP ElJGF 0 LPG! ElCORPORATION❑# PARTNERSHIP El#[ Lc ❑# COMPANY NAME: Scott Reid ADDRESS. PO Box 222, CITY Harwich Port STATE MA ZIP 026460222 TEL FAX CELL EMAIL 4 ` 9- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# Ictur PLAN REVIEW NOTES n-zo/i-c vim i /O/40/4