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HomeMy WebLinkAboutBLDG-22-005812 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '1,(7.1-.1i CITY YARMOUTH MA DATE April 12,2022 PERMIT# BLDG-22-005812 JOBSITE ADDRESS 42 CHARLES ST OWNER'S NAME MASON MADELINE J TR G OWNER ADDRESS IM J MASON FAMILY TRUST 42 CHARLES ST SOUTH YARMOUTH MA 02664-3104 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 111 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 _BOOSTER _ _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El 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 LICENSE# SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ADDRESS. CITY STATE ZIP , TEL FAX CELL EMAIL S310N M31A321 NVId #111A1i3d $:33d ❑ ❑ 111U3d 3E11 SV S3A213S N011VOIlddV SIHI oN seA S310N N01133dSNI IVNId AINO 3Sfl H0103dSNI ilOd 30Vd SIHI S310N N01133dSNI SVO HOflO