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HomeMy WebLinkAboutBLDG-19-000409 4'/9- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "l CITY YARMOUTH I MA DATE July 19,2018 PERMIT# BLDG-19-000409 JOBSITE ADDRESS 32 CANTERBURY RD OWNER'S NAME LARIMORE MARGARET A(LIFE EST) G OWNER ADDRESS OLEARY LISA J TR 32 CANTERBURY RD YARMOUTH PORT MA 02675 TEL TYPE 012 OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY 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 wafter nye LICENSE# 32083 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS 349 great western road, CITY harwich STATE MA ZIP 02645 TEL FAX CELL 5082463349 EMAIL } 2 -24e #k-?,) SalON MaIA221 NV1d #±IW2idd $ :ddd lIWHRd Hl SY SAHS NOIlVOIlddV SIHl ON SG), ShcON NOILOddSNI A-INO dSfl 2:1O10ddSNI 20d dEVd SIHl SALON NOIlJAdSNI SVJ HJfOH