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HomeMy WebLinkAboutBLDG-23-002115 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ""' CITY YARMOUTH MA DATE October 20,2022 PERMIT# BLDG-23 002115 T,44, JOBSITE ADDRESS 29 CAPT DORE RD OWNER'S NAME THOMAS PAUL P G OWNER ADDRESS 29 CAPT DORE RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO FIXTURES FLOORS--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER , COOK STOVE . DIRECT VENT HEATER DRYER , FIREPLACE FRYOLATOR . FURNACE . GENERATOR GRILLE . INFRARED HEATER , LABORATORY COCKS , MAKEUP AIR UNIT OVEN . POOL HEATER . ROOM I 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❑ 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 (John Perez I LICENSE# (Massachusetts SIGNATURE MP 0 MGF ❑ JP 0 JGF❑ LPGI 0 CORPORATION 0#I PARTNERSHIP ❑#I LLC 0# COMPANY NAME: (Harbor Master Plumbing&Heating Inc. ADDRESS. 17 Van Gogh Drive, I CITY IOsterville I STATE MA ZIP 102655 I TEL 15084191592 FAX 15086525272 I CELL 15086812599 EMAIL I