HomeMy WebLinkAboutBLDG-22-004348 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
raleg CITY YARMOUTH MA DATE February 04,2022 PERMIT# BLDG-22-004348
i ,>
JOBSITE ADDRESS 8 POWHATAN RD OWNER'S NAME FLYNN CATHERINE H LIFE EST
G OWNER ADDRESS 8 POWHATAN RD SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El
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 1
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 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 El 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❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑#
COMPANY NAME: ADDRESS.
CITY STATE ZIP TEL
FAX CELL EMAIL
S3 LON M3IA32J NVId
#1I1Al2J3d $ 33d
❑ ❑ II1A183d 3111 SV S3A S NOI1VOIlddV SIHI
oN seA
S31ON N01133dSNI 1VNld AINO 3Sl 210103dSNI 21Od 30Vd SIN! S31ON NOI133dSNI SVO H`Of1021