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HomeMy WebLinkAboutBLDG-21-006696 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �` � CITY YARMOUTH MA DATE May 18,2021 PERMIT# BLDG-21-006696 '-; JOBSITE ADDRESS 33 SHORE RD OWNER'S NAME DOLINER SUSAN G OWNER ADDRESS DOLINER SUSAN 20 MERRIMAC PL CAPE ELIZABETH ME 04107 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL 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 I 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 ❑ 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 'Matthew Coleman I LICENSE# 134368 MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑#I I PARTNERSHIP ❑# SIGNATURE COMPANY NAME: 'matt coleman plumbing and heatingI Inc ❑#I I ADDRESS. 18 Pine Pond Rd, CITY (Brewster I STATE IMA I ZIP 102631 I TEL 19788854343 FAX I 1 CELL I I EMAIL I