HomeMy WebLinkAboutBLDG-23-000373 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r F CITY 'YARMOUTH I MA DATE 'July23,2022 I PERMIT# BLDG-23-000373
JOBSITE ADDRESS 1162 SPRINGER LN I OWNER'S NAME 'MORRISON LYLE D III TRS
G OWNER ADDRESS MORRISON ANDREA S TRS 11 CHADBOURNE RD LEXINGTON MA 02421 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES El NO El
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/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 El
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY El BOND El
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 LICENSE# SIGNATURE
MP❑MGF❑JP El JGF❑ LPGI 0 CORPORATION El# _ PARTNERSHIP ❑# LLC El#
COMPANY NAME: ADDRESS.
CITY STATE ZIP TEL
FAX CELL F EMAIL
S310N M3IA32I NV1d
#1IW2i3d $:33d
❑ ❑ 1111213d 3H1 SV S3A213S N011V011ddd SIHL
ON SeA
S31ON NOI103dSNI 1VNId A1NO 3sn 101O3dSNI 21Od 3JVd SIHI S310N NOI103dSNI SVO HJl0H