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HomeMy WebLinkAboutBLDG-22-05756 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK VI°' 1 CITY 'YARMOUTH I MA DATE 'April 08,2022 I PERMIT# BLDG-22-005756 �- JOBSITE ADDRESS 115 HORSE POND RD I OWNERS NAME ROBINSON PAUL A G OWNER ADDRESS ROBINSON CLAUDIA C 15 HORSE POND RD WEST YARMOUTH MA 02673 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES© NO 0 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 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 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 El 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 I LICENSE# 13DB SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPG'0 CORPORATION 0# PARTNERSHIP ❑# LLC❑#1 COMPANY NAME: (SEASIDE GAS SERVICE INC I ADDRESS. 167 Helmsman Dr, CITY 'Yarmouth Port 'STATE MA ZIP 102675 TEL 15087712768 FAX I I CELL 15084000943 I EMAIL I S310N M31A1:1 NVld #UIW2l3d $ :33d 11141213d 3H1 Sd SAS NOI1d01lddd SIHl oN SeA S310N NO1103dSNI lYNId AlNO 3Sfl 2J0103dSNI 210d 3OVd SIHI S31ON NO1103dSNI SVO HOf10d