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HomeMy WebLinkAboutBLDG-23-001215 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK y pl CITY YARMOUTH MA DATE September 06,202 PERMIT# BLDG-23-001215 a JOBSITE ADDRESS 217 SOUTH SHORE DR OWNERS NAME KOKORAS CHRISTOPHER G OWNER ADDRESS P 0 BOX 790 WINCHESTER MA 01890 _ TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO ❑ 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 - _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ OTHER I I • 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 0 BOND 0 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❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768 FAX CELL 5084000943 EMAIL S310N M3IA3N NVId #11W213d $ 33d ❑ ❑ 11W213d 31-11 SV S3Ad3S N011V3IlddV SIH1 oN saA S310N NO1103dSNI 1VNId AINO 3Sl 210103dSNI 2:10J 30Vd SIH1 S310N NO1103dSNI SVO HOflOU