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HomeMy WebLinkAboutBLDG-22-004257 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k:Ingl, CITY YARMOUTH MA DATE January 31,2022 PERMIT# BLDG-22-004257 JOBSITE ADDRESS 11 LONGFELLOW DR OWNER'S NAME WOODWARD JOSHUA L G OWNER ADDRESS WOODWARD DONNA L 11 LONGFELLOW DRIVE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ 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 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 El 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 Cameron Natale LICENSE# MA SIGNATURE MP❑ MGF El JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 200 Audreys Lane, CITY Marstons Mills STATE MA ZIP 02648 TEL FAX 5085341272 CELL 7743537354 EMAIL S310N M31A321 NV1d #1IIN213d $:33d ❑ ❑ 1111213d 3H1 SV S3A113S NOIlVOIlddtl SIHl ON S8A S310N N01103dSNI lYNId AINO 3Sl 210103dSNI LIOd 3OVd SIHl S310N NO1103dSNI SVO HOf1021