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HomeMy WebLinkAboutBLDG-22-006888 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ir CITY YARMOUTH MA DATE I May 30,2022 'PERMIT# BLDG-22-006888 JOBSITE ADDRESS 1070 81074 ROUTE 28 OWNER'S NAME DAVENPORT DEWITT TR G OWNER ADDRESS 20 NORTH MAIN ST SOUTH YARMOUTH MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL J❑ RESIDENTIAL❑ PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO El 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 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 1 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 LICENSE# SIGNATURE MP 0 MGF❑JP 0 JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: I I ADDRESS. I CITY I STATE ZIP TEL FAX CELL EMAIL I S310N M3IA321 NVld #11 V1H3d $ :33d ❑ ❑ 111V:13d 3H1 SV S3NES NOIiV011dd`d SIH1 oN saA S31ON NO1103dSNI lYNId AlNO 3Sfl Z10103dSNI:10d 30Vd SIHI S31ON NO1103dSNI SVO HJf O I