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HomeMy WebLinkAboutBLDG-18-006427 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE May 16, 2018 PERMIT# BLDG-18-006427 JOBSITE ADDRESS 19 CAPT BESSE RD OWNER'S NAME LOVELY DOROTHY A TR G OWNER ADDRESS LOVELY REALTY TRUST 19 CAPT BESSE RD SOUTH YARMOUTH MA TEL 02664 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 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 ❑ 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 Walter Nye LICENSE# 32083 SIGNATURE MP❑ MGF❑ JP© JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS 349 Great Western Road, CITY Harwich STATE MA ZIP 02645 TEL FAX CELL EMAIL 4t ,g//e/g- 5y9 ���2J S31ON M3IA I NV1d # $:33d ❑ ❑11141213d 3H1 SY S3ALI3S NOI1VOIlddV SIHI oN saA S31ON NO1103dSNI 1VNId A1NO 3Sf1 2JO103dSNI 2fOd 30Vd SIHl S31ON NO11O3dSNl SVD HE)fON ti