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HomeMy WebLinkAboutBLDG-23-003647 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK A' CITY E t I- IYARMOUTH MA DATE January 05,2023 PERMIT# BLDG-23-003647 JOBSITE ADDRESS 131 WALTHAM CIR OWNER'S NAME (BOY EVERETT W JR TR G OWNER ADDRESS THE WALTHAM CIRCLE RLTY TRUST P 0 BOX 186 WEST DENNIS MA 02670 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL ID CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO al FIXTURES FLOORS-I 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 • 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 0 BOND 0 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 (Cameron Natale I LICENSE# 14600 I SIGNATURE MP 0 MGF © JP❑ JGF❑ LPGI ❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑# COMPANY NAME: I ADDRESS. 1200 Audreys Lane, CITY IMarstons Mills I STATE IMA I ZIP 1026482648 I TEL 15087753083 FAX I I CELL I I EMAIL I