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HomeMy WebLinkAboutBLDG-22-002739 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1-fr CITY YARMOUTH MA DATE November 12,202'PERMIT# BLDG-22-002739 JOBSITE ADDRESS 8 BURCH RD OWNERS NAME MARK KYER G OWNER ADDRESS 8 BURCH RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q 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 1 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 Q OTHER OF INDEMNITY El 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 Kevin Sargent LICENSE# PL-16471-M SIGNATURE MP❑MGF Q JP 0 JGF 0 LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: CAPE COD GAS HEAT&A/C SYSTEMS J ADDRESS. 115 JAN SEBASTIAN DR STE 4D, CITY !Sandwich ISTATE MA ZIP 02563 TEL 15085399303 FAX CELL 6178340785 EMAIL I S310N M31/13N NVld #JIWH3d $ :33d 0 El 1I1N2i3d 3H1 SV S3A2l3S NOLLVO lddd SIHl oN seA S310N N01109dSNI 1VMd AlN0 3Sf1 ,10103dSNI 210d 3OVd SIHl S310N N01103dSNI St/9 HOflOH