HomeMy WebLinkAboutBLDG-23-000040 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 'YARMOUTH I MA DATE (July 05,2022 I PERMIT# BLDG-23-000040
JOBSITE ADDRESS 156 SUFFOLK AVE I OWNER'S NAME LYNCH ROBERT T
OWNER ADDRESS LYNCH ELIZABETH E 56 SUFFOLK AVE WEST YARMOUTH MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 LICENSE# SIGNATURE
MP El MGF 0 JP❑ JGF❑ LPG'❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: ADDRESS.
CITY STATE ZIP TEL
FAX CELL EMAIL
S310N MJI/13b NVld
#1IVkI3d $ :33d
❑ ❑ 1116N3d 3HI SV S3AH3S NOliV011ddd SIHJ
oN saA
S310N N01103dSNI 1VNId AlN0 3Sfl 10103dSNI 2IOd 3OVd SIH1 S310N NOI103dSNI SYJ HJf102I