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HomeMy WebLinkAboutBLDG-22-006228 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ._._......... CITY 'YARMOUTH MA DATE IApri128,2022 IPERMIT# BLDG-22-006228 IJ, '�- JOBSITE ADDRESS 1 TURNER LN OWNER'S NAME PINA DEBRA J THOMSON G OWNER ADDRESS 1 TURNER LN SOUTH YARMOUTH MA 02664-3141 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 0 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 Kevin Saunders LICENSE# 308 SIGNATURE MP 0 MGF❑JP❑ JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP ❑#1 LLC 0# COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768 _ _I FAX CELL 5084000943 EMAIL S3ION M31A0:1 Ndld #lIWZl3d $:33d iJ1N83d 3H1 SY S3A213S NOI1V011ddV SIHJ oN saA S310N NOI103dSNI 1VNId NINO 3Sl 2I0103dSNI 2iOd 3OVd SIHI S310N N01103dSNI SYO HJfO 1