HomeMy WebLinkAboutBLDG-22-02457 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Ir1q CITY YARMOUTH MA DATE 'October 29,2021 IPERMIT# BLDG-22-002457
JOBSITE ADDRESS 73 SILVER LEAF LN OWNERS NAME Stephen Nadeau
G OWNER ADDRESS TEL
TYPE.OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ill
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BOILER
BOOSTER -
CONVERSION BURNER -
COOK STOVE 1 _
DIRECT VENT HEATER _
DRYER _ -
FIREPLACE 1 _ -
_
FRYOLATOR _ _
FURNACE 1 _ _ _
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❑
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY ID 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 MI plumbing work and installations performed under the permit Issued for this application will be in compliance with At Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME William Eastman LICENSE# 32766 SIGNATURE
MP❑MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME. WILLIAM W EASTMAN ADDRESS. 36 Sun Hill Rd,
CITY West Barnstable STATE MA ZIP 026661534 TEL
FAX CELL EMAIL bill eastmanoncomcast.net
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY �C5L YOrC3U1i MA DATE t 0 E8 21 PERMIT# -z
Z- 241 S-7
JOBSITE ADDRESS - 5 I l— OWNER'S NAME S}e eh Na.d tc
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E)
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER
DRYER
FIREPLACE I
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 I
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY NI OTHER TYPE 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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#.32.7((.0 SIGNATURE
MP❑ MGF❑ JP JGF❑ PGI ❑ CORPORATION❑# PARTNERSHIP❑it LLC❑#
COMPANY NAME L UI J ( 411,1-y bt' ADDRESS 3 (o So 1
n � 0 Z6 TEL
CITY ��S G�' S STATE � ZIP iL
6�FAX CELL174`Z)S-Li&3(3 EMAIL 6l ect,s ln0'\- Q COevt rte.;