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HomeMy WebLinkAboutBLDG-22-003707 �p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ( CITY (YARMOUTH k I MA DATE (January 04,2022 (PERMIT# G22 003707 JOBSITE ADDRESS 111 OLD SALT LN J OWNER'S NAME (GUISE C NICHOLAS TRS I G OWNER ADDRESS (GUISE CATHY C TRS 93 JENKINS RD ANDOVER MA 01810 TYPE OR I TEL I I OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT El CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS—. BOILER BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 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 1 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 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 MP 0 MGF ElJP 0 JGF 0 LPGI El CORPORATION L❑#SE PAR LSIGNATURE TNERSHIP ❑#I ILLC 0#I I COMPANY NAME: ADDRESS. CITY STATE ��ZIP =TEL FAX CELL EMAIL