HomeMy WebLinkAboutBLDG-22-005360 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
* 4.p CITY YARMOUTH MA DATE March 24,2022 PERMIT# BLDG-22-005360
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JOBSITE ADDRESS 908&928 ROUTE 28 OWNER'S NAME BASS RIVER REALTY LLC
G OWNER ADDRESS p113 PLEASANT ST SOUTH YARMOUTH MA 02664 TEL,
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: 0 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
FRYOLATOR
FURNACE
GENERATOR 1
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1
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❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ 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 William Holmes LICENSE# 4592 SIGNATURE
MP❑ MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: ADDRESS. 9 Hunters Trail.
CITY Sandwich STATE MA ZIP 025632701 TEL
FAX CELL EMAIL
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