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HomeMy WebLinkAboutBLDG-22-003069 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 9 - CITY YARMOUTH MA DATE (November 29,2021 PERMIT# BLDG-22-003069 JOBSITE ADDRESS 122 PAWNEE RD I OWNERS NAME !BOWEN KAREN L .._ __1 G OWNER ADDRESS ANTOINE CARLETON B&KRISTIN L 937 PLYMOUTH ST ABINGTON MA 02351 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 1 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 1 OTHER r 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 Q OTHER OF INDEMNITY ID BOND 0 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 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX I I CELL EMAIL S3 LON M3IA H Ndld #iIIN13d $ :33d El 1:1 1IW213d 3H1 SV S3A213S NOI1VOIlddV SIH1 oN saA S310N N01103dSNI 1VNId A-NO 3Sfl 1O103dSNI 210d 3OVd SIH1 S31ON NO1133dSNI SVO HJl0H