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HomeMy WebLinkAboutBLDG-21-004669 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY YARMOUTH MA DATE (February 17,2021 PERMIT# BLDG-21-004669 JOBSITE ADDRESS 129 SILVER LEAF LN OWNER'S NAME SANCHEZ PRISCILLA A G OWNER ADDRESS 303 BROOKSBY VILLAGE DR#721 PEABODY MA 01960 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT LiRESIDENTIAL El CLEARLY NEW: ❑ 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 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 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 Ibrian hibbard I LICENSE# 111977 MP© MGF ❑ JP❑ JGF❑ LPGI 0 CORPORATION❑#I I PARTNERSHIP ❑#I SIGNATURE COMPANY NAME: (cape cod plumbing and heatinginc I ❑#I I I ADDRESS. Ipo box 429, I CITY (south dennis 'STATE IMA J ZIP 102660 I TEL 15083982228 I FAX 1 I CELL I I EMAIL I I