Loading...
HomeMy WebLinkAboutBLDG-22-004089 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 24,2022 PERMIT# BLDG-22-004089 �I— R JOBSITE ADDRESS 34 ARROWHEAD DR OWNER'S NAME SOLOMON STEVEN F G OWNER ADDRESS SOLOMON ELIZABETH F 34 ARROWHEAD DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY 0 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 Derek LeClerc LICENSE# 26022 SIGNATURE MP❑MGF❑JP El JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME Derek co plumbing and heating ADDRESS. P.O.Box 1248, CITY Forestdale STATE MA ZIP 02644 TEL FAX CELL 5082927249 EMAIL S310N M3IA32J NVld #1111213d $ :33d ❑ ❑ 1IV d 3H1 SV S3A213S NOI1VOIlddV SIHI oN saA S310N N01103dSNI IVNH N NO 3Sl 2J0103dSNi 2JOd 30Vd SIH1 S310N N01103dSNI SVO HOflO