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HomeMy WebLinkAboutBLDG-22-001048 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' y„ CITY YARMOUTH MA DATE rAugust 24,2021 PERMIT# BLDG-22-001048 I I d JOBSITE ADDRESS 29 OCEAN AVE OWNER'S NAME MILLER HENRY B G OWNER ADDRESS MILLER CAROL 7924 SW 115TH LOOP OCALA FL 34476 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑ FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © 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 'Kevin Saunders LICENSE# 1308 SIGNATURE MP❑ MGF 0 JP 0 JGF 0 LPG( ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: 'SEASIDE GAS SERVICE INC ADDRESS. 167 Helmsman Dr, CITY 'Yarmouth Port STATE MA ZIP 02675 TEL 15087712768 FAX 1 CELL 15084000943 EMAIL 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT D 0 FEE:$ PERMIT# PLAN REVIEW NOTES