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HomeMy WebLinkAboutBLDG-22-006156 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE April26,2022 PERMIT# BLDG-22-006156 JOBSITE ADDRESS 11 TODD RD OWNERS NAME RAFTERY JOHN P TR(EST OF) G OWNER ADDRESS C/O DON RAFTERY 120 WOODSIDE DR GREENWICH CT 06830 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 111 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 - 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 ifs 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 ID 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 t 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 0 MGF❑JP 0 JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: I I ADDRESS. I CITY I I STATE ZIP TEL I FAX CELL I I EMAIL I S310N M3IA3 I Ndld #i LN I3d $ :33d ❑ 0 iIINa3d 3H1 SV S3a13S NOI1V011dd`d SIHI ON SeA S310N N01103dSNI 1VNId AlN0 3sn 10103dSNI 2i0d 3OVd SI1-11 S310N N01103dSNI SVO HJl0b