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HomeMy WebLinkAboutBLDG-23-004057 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ------ CITY IYARMOUTH MA DATE (January 23,2023 PERMIT# BLDG-23-004057 JOBSITE ADDRESS 119 BASS RIVER PKWY OWNER'S NAME 'JACKSON WILLIAM W G OWNER ADDRESS 'JACKSON MARY LOU T 32 BERKSHIRE ST NORFOLK MA 02056 1 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO FIXTURES FLOORS—4 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 1 1 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 ❑ 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 (Braga Inc. I LICENSE# (Massachusetts I SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑#I I PARTNERSHIP ID#I Inc ❑#I COMPANY NAME: (Braga Brothers Inc I ADDRESS. 1110 breeds hill road Unit#5, CITY 'Hyannis ISTATE IMA I ZIP 1920:_11,962L1 TEL 5088274260 FAX I I CELL 17748870199 I EMAIL