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HomeMy WebLinkAboutBLDG-22-007040 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kMA:,e �� CITY YARMOUTH DATE June 06,2022 PERMIT# BLDG-22 007040 o`er JOBSITE ADDRESS 99 ROUTE 6A OWNER'S NAME DOHERTY JOHN W TRS G OWNER ADDRESS DOHERTY MARTHA P 727 W ROXBURY PKWY BOSTON MA 02132-2107 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL El CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO FIXTURES FLOORS—. 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El 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 MP 0 MGF El JP El JGF El LPG! 0 CORPORATION El#I I SIGNATURE PARTNERSHIP ❑#I ILLC 0#I I COMPANY NAME: I I ADDRESS. 1200 Audreys Lane, CITY IMarstons Mills I STATE IMA I ZIP 102648 I ITELI I FAX I I CELL 17743537354 I EMAIL I I S310N M3IA321 NVld #11M3d $ :33d .I11V3d 3H16V S3A1:13S NOI1`d3llddv SIHI oN sa). S310N NO1103dSNI 1VNId AlNO 3Sf1 Z10103dSNI 2I0d 3DVd SIHI S310N NO1103dSNI SVO HOf1021