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HomeMy WebLinkAboutBLDG-22-00352 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH MA DATE (July 20,2021 'PERMIT# BLDG-22-000352 JOBSITE ADDRESS 78 RIVER ST OWNER'S NAME ICLARK JOHN R G OWNER ADDRESS IPRATT CAROLYN J 332 CONCORD RD WAYLAND MA 01778 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL III CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO El 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 1 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. III NO ❑ YES 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 MP ID MGF 0 JP ID JGF❑ LPG! El CORPORATION L❑#LICENSE # SIGNATURE I I PARTNERSHIP 0#I ILLC ❑#� COMPANY NAME: I ADDRESS. CITY I ISTATE L J I ZIP I-- TEL FAX I CELL EMAIL