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HomeMy WebLinkAboutBLDG-22-006231 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a,L E/ CITY 'YARMOUTH I MA DATE (April 28,2022 I PERMIT# BLDG-22-006231 JOBSITE ADDRESS 119 CAPT BESSE RD I OWNER'S NAME ILOVELY DOROTHY A TR I G OWNER ADDRESS 'LOVELY REALTY TRUST 19 CAPT BESSE RD SOUTH YARMOUTH MA 02664 I TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT 0 RESIDENTIAL El CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO ID 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 1 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. © NO❑ YES IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY El BOND El 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 'Stephen Roberts I LICENSE# 15105 I MP 0 MGF'❑ JP❑ JGF ID LPG! ❑ CORPORATION ID#I I SIGNATURE PARTNERSHIP 0#I ILLC ❑#' I COMPANY NAME: ' I ADDRESS. 117 lake dr, CITY 'Plymouth I STATE 'MA I ZIP 102360 I TEL I I FAX 1 I CELL I I EMAIL I I