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HomeMy WebLinkAboutBLDG-22-002929 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH‘4,,,, I MA DATE (November 19,202 I PERMIT# JOBSITE ADDRESS 118 NORTH SANDYSIDE LN I OWNER'S NAME ILINK JUDITH A BLDG-22-002929 G OWNER ADDRESS 160 WITHERELL DR SUDBURY MA 01776 TYPE OR I TEL I I OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO El FIXTURES FLOORS-4 BOILER BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 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 Fernando Coelho LICENSE# 34508 SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC 0#� COMPANY NAME: ADDRESS. 16 Wildwood Path, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL fernando252c(c�pmail.com