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HomeMy WebLinkAboutBLDG-21-002021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t'10--) CITY IYARMOUTH I MA DATE 'October 16,2020 I PERMIT# BLDG-21-002021 �+ JOBSITE ADDRESS 196 SHAKER HOUSE RD I OWNER'S NAME 'BOYNTON CYRUS K JR TRS G OWNER ADDRESS IBOYNTON VICTORIA TRS 96 SHAKER HOUSE RD YARMOUTH PORT MA 02675 I TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES © NO 0 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 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 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 'Kevin Saunders I LICENSE# 1308 MP I: MGF ❑ JP 0 JGF 0 LPGI I: CORPORATION 0#I SIGNATURE I PARTNERSHIP ❑#I_____ILLC ❑#I I COMPANY NAME: ISEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr, CITY 'Yarmouth Port 'STATE MA ZIP 02675 TEL 5087712768 _FAX 1 1 CELL 15084000943 I EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .�, 7 CITY YARMOUTH ytl-�v MA DATE October 16,2020 I PERMIT# BLDG-21-002021 JOBSITE ADDRESS 96 SHAKER HOUSE RD !OWNER'S NAME BOYNTON CYRUS K JR TRS G OWNER ADDRESS BOYNTON VICTORIA TRS 96 SHAKER HOUSE RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL CLEARLY NEW: F❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES El NO 0 ORS FIXTURES 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 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 El 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 'Kevin Saunders I LICENSE# 1308 I MP❑ MGF ElJP 0 JGF❑ LPGI ❑ CORPORATION El#I I PARTNERSHIP El#I SIGNATURE RE COMPANY NAME: 'SEASIDE GAS SERVICE INC I ADDRESS. IncI 0#) 167 Helmsman Dr, CITY 'Yarmouth Port I STATE IMA I ZIP 102675 'TEL 15087712768 FAX ' 'CELL 15084000943 1 EMAIL I 1 c C1I - /oh/5Jza z o Cr=s