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BLDG-23-004420 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I. =- ------ 4"1 CITY IYARMOUTH MA DATE February 09,2023 PERMIT# BLDP-23-004420 JOBSITE ADDRESS 161 SEAVIEW AVE OWNER'S NAME ICOTE STEPHEN G G OWNER ADDRESS COTE LYNN A 125 SOULE RD WILBRAHAM MA 01095 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES ❑ NO 111 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/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 El 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 brian hibbard LICENSE# 11977 SIGNATURE MP El MGF ❑ JP 0 JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC El# COMPANY NAME: cape cod plumbing and heating ADDRESS. po box 429, • CITY south dennis STATE MA ZIP 026600000 TEL 5083982228 FAX CELL EMAIL