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HomeMy WebLinkAboutBLDG-22-006839 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ",41 CITY 'YARMOUTH I MA DATE IMay 25,2022 I PERMIT# BLDG-22-006839 JOBSITE ADDRESS I107081074 ROUTE 28 I OWNER'S NAME DAVENPORT DEWITT TR G OWNER ADDRESS 20 NORTH MAIN ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 1:1 RESIDENTIAL❑ PRINT 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 1 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 © 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 M 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 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS, I CITY I I STATE ZIP TEL I FAX CELL 1 I EMAIL I S310N M3IA3b NV1d #.IWRAd $:333 El 0 1IW213d 31-11 SV S3A2i3S NOI1VOIlddd SIHl oN saA 3310N N01103dSNI 1VNId AlNO 3Sfl M.03dSNI 2iO3 3OVd SIHI S310N N01103dSNI SVO HOflO 1