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HomeMy WebLinkAboutBLDG-23-002893 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK  e 'WU—_ CITY IYARMOUTH I MA DATE (November 28,202I PERMIT# BLDG-23-002893 JOBSITE ADDRESS 15 OLYMPIA DR I OWNER'S NAME IADDONIZIO OLYMPIA G OWNER ADDRESS IADDONIZIO NICHOLAS A 5 OLYMPIA DR SOUTH YARMOUTH MA 02664 TYPE OR I TEL I OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL O PRINT CLEARLY NEW: 0 RENOVATION:O REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO O FIXTURES FLOORS BSM 1 2 3 4 5 6 7 BOILER 8 9 10 11 12 13 14 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/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 0 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 Eric Whiteley LICENSE I MP O MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION # I15920 0# SIGNATURE �� PARTNERSHIP ❑# �LLC ❑#� COMPANY NAME: W Vernon Whiteley, Inc ADDRESS. PO Box 1266, CITY W Chatham STATE MA ZIP 026691266 TEL 5089451100 FAX CELL EMAIL