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HomeMy WebLinkAboutBLDG-22-002165 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ern e CITY YARMOUTH MA DATE October 15,2021 PERMIT# BLDG-22-002165 JOBSITE ADDRESS 62 GREAT WESTERN RD OWNERS NAME CONWAY ELIZABETH L TR G OWNER ADDRESS 2262 RLTY TRUST 345 CAMP ST UNIT 105 WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL al PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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 1 DIRECT VENT HEATER DRYER 1 ::\.- ) / FIREPLACE FRYOLATOR FURNACE 1 GENERATOR \ / ._ . GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ..\ 1 :..._). . . OVEN • POOL HEATER _ ROOM/SPACE HEATER _ ROOF TOP UNIT _ TEST 1 _ _ UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER 1 _ 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 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 Phillip Durfee LICENSE# 13774 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# , PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 51 Flax Street, CITY Dennis STATE MA ZIP 02638 TEL 5088018004 FAX CELL EMAIL S310N M3IA38 NVId #JIIJ d $:333 ❑ 0 11161113d 3H1 SV S3A213S NOI1V3IlddV SIHl ON saA S310N NO1133dSNI IVNId AINO 3Sf1 N0133dSNI a0d 3OVd SIN' S310N N01133dSNI SYS HOf10a