HomeMy WebLinkAboutBLDG-22-004526 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ti,lit-74 CITY 'YARMOUTH I MA DATE (February 14,2022 I PERMIT# BLDG-22-004526
!rF JOBSITE ADDRESS 115 SHORE RD I OWNER'S NAME DUCOTE LINDA LORENE TRS
G OWNER ADDRESS DUCOTE DOUGLAS A JR TRS 42 MARQUISE OAKS PL SPRING TX 77382-1082 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ID
PRINT
CLEARLY NEW: 0 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
GENERATOR 1
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
•
OVEN
POOL HEATER _
ROOMI SPACE HEATER •
ROOF TOP UNIT _
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
—OTHER 1 •
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY El BOND ❑
OWNER'S INSURANCE WAIVER:1 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# 14592 I SIGNATURE
MP 0 MGF 0 JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: ADDRESS, 9 Hunters Trail,
CITY Sandwich STATE MA ZIP 025632701 TEL
FAX CELL EMAIL
S310N M31A32i NYld
#.I J fld $:333
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