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HomeMy WebLinkAboutBLDG-20-002303 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 23,2019 PERMIT# BLDG-20-002303 II -`� JOBSITE ADDRESS 654 WILLOW ST OWNER'S NAME BOOSAHDA STEPHANIE E G OWNER ADDRESS 654 WILLOW STREET SOUTH YARMOUTH MA 02664-5636 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL En PRINT 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 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN • POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT • TEST • UNIT HEATER • UNVENTED ROOM HEATER • WATER HEATER OTHER 1 • OTHER DESCRIPTION: /Z1=rihpvg: /-01 j) (/ 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 ❑ 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 Whiteside LICENSE# 15850 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: RICHARD J WHITESIDE ADDRESS. 29 MAPLE TER, CITY SOUTH DENNIS STATE MA ZIP L026603651 TEL FAX CELL EMAIL a 4 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �� 7/ 7