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HomeMy WebLinkAboutBLDG-23-000276 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W' CITY YARMOUTH MA DATE July 18,2022 PERMIT# BLDG-23-000276 , JOBSITE ADDRESS 327 WHITES PATH OWNER'S NAME FANARA BETH ADAIR TRS G OWNER ADDRESS FANARA REV TRUST P 0 BOX 775 DENNIS MA 02638 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 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 © 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 'John Downey I LICENSE# IMA SIGNATURE MP 0 MGF 0 JP© JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP ❑# Lc❑#I COMPANY NAME: I I ADDRESS. 137 Bray Farm Road North, CITY (Yarmouth Port STATE MA ZIP 102675 I TEL 15082215257 FAX 1 ICELL 1 IEMAIL I S310N MIANOIARI NVld #iIW2i3d $ :33d 0 El 111*Ed 3H1 SV S3A213S NOILV011ddd SIHI oN saA 'I"MU AINO 3Sfl 2i0103dSNI 2iOd 3OVd SIH1 S310N NOI103dSNI SVO Ronal