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HomeMy WebLinkAboutBLDG-23-000524 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s CITY YARMOUTH MA DATE August 02,2022 PERMIT# BLDG-23-000524 ��_--__. JOBSITE ADDRESS r16 SWIFT BROOK RD OWNER'S NAME DOWNEY JOHN T G OWNER ADDRESS CRUPI M G 8 C G 76 SWIFT BROOK RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT❑ PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS-s 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 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 LABILITY 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 Stephen Roberts LICENSE# [5104 SIGNATURE MP❑MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# J PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. 17 lake dr, CITY Plymouth STATE MA ZIP 02360 TEL FAX CELL 5086480900 EMAIL S310N M3IA321 NYld # Hd $:33d ❑ ❑ 111%13d 3Hl SV S3A2:13S NOLLV011ddV SIHl oN saA S310N N01103dSNI 1VNId AlN0 3Sfl 80103dSNI H03 3OVd SIHI S310N N01103dSNI SVO HJl02!