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HomeMy WebLinkAboutBLDG-22-006508 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i07,--110,174 CITY YARMOUTH MA DATE May 11,2022 PERMIT# BLDG-22-006508 V JOBSITE ADDRESS 2 ALISON LN OWNER'S NAME BARTLEY DOUGLAS G OWNER ADDRESS BARTLEY NANCY A 4 WOLFSON RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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 1 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 1 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 KEVIN LAMOUREUX LICENSE# 15383 SIGNATURE MP© MGF D JP❑ JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 61 JOBYS LANE, CITY OSTERVILLE STATE MA ZIP 02655 TEL 5084202068 FAX CELL EMAIL S310N M3IA321 NVId #11W213d $:33d ❑ ❑ 111U3d 3H1 SV S3A83S NOI LVOIlddV SIHl oN saA S310N N01103dSNI 1VNIJ AlN0 3Sl 210103dSNI HOd 30Vd SIH1 S310N N01103dSNI SVO HJflO21