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HomeMy WebLinkAboutBLDG-22-004060 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' "� CITY YARMOUTH MA DATE January23,2022 PERMIT# BLDG-22-004060 f JOBSITE ADDRESS 1233 CRANBERRY LN I OWNERS NAME LAWTON GARY R G OWNER ADDRESS LAWTON C M G R JR&K M 15 WAYCROSS ST WORCESTER MA 01605 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: m 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 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 0 IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY❑ BOND ❑ OWNERS 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 Jonathan Cirrone LICENSE# 16297 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: JC Plumbing ADDRESS. 190 Front St., CITY Ashland STATE MA ZIP 01721 TEL FAX 1 I CELL 5087284446 EMAIL S310N M31A321 Ndlld # LW dad $ :33d 11WH3d 31-11 SV S3AH3S NOIlVOIlddV SIH1 oN saA S310N NOI103dSNI IVNId )ClNO 3Sfl JO103dSNI 2IOd 30Vd SIHl S310N NOI103dSNI SVJ HOflO