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HomeMy WebLinkAboutBLDG-21-006664 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK E�i BLDG-21-006664 CITY YARMOUTH MA DATE May 18,2021 PERMIT# 1,710 1af_ ,. k JOBSITE ADDRESS 200 SOUTH SEA AVE OWNER'S NAME REISMAN PAUL P G OWNER ADDRESS REISMAN MARIA 75 JOHNSON RD SCARSDALE NY 10583 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ 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 1 DIRECT VENT HEATER . DRYER . FIREPLACE . 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY❑ 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 Christopher Keith LICENSE# 16690-M-PL SIGNATURE MP 0 MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Keith Brothers Plumbing,Inc. ADDRESS. 19 Milford Street, CITY Plymouth STATE MA ZIP 02360 TEL 5083178577 FAX CELL 5083176373 EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES