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HomeMy WebLinkAboutBLDG-23-001370 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lilt YARMOUTH MA DATE September 14,202 PERMIT# BLDG-23-001370 JOBSITE ADDRESS 24 EASY ST OWNER'S NAME SAM SPEAKMAN LLC G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL ❑ PRINT 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 2 GENERATOR • GRILLE INFRARED HEATER • LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER 2 • 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 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 Daniel CASEY LICENSE# 13768 SIGNATURE MP El MGF ❑ JP El JGF❑ LPGI El CORPORATION❑# PARTNERSHIP ❑# LLC El# COMPANY NAME: Casey Plumbing&Heating,Inc. ADDRESS. PO BOX 404, CITY HARWICH PORT STATE MA ZIP 02646 TEL 5084323233 FAX CELL 5082741975 EMAIL I