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HomeMy WebLinkAboutBLDG-22-004023 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK — CITY YARMOUTH MA DATE January 20,2022 PERMIT# BLDG-22-004023 1 JOBSITE ADDRESS 21 FLINTLOCK WAY OWNERS NAME MUDIE KENNETH G OWNER ADDRESS MUDIE DONNA M 21 FLINTLOCK WAY YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES El NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 6 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 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 © NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY BOND ❑ OWNERS 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 E 4592 SIGNATURE MP 0 MGF El JP El JGF 0 LPG] ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: ADDRESS. 9 Hunters Trail, CITY Sandwich STATE MA ZIP 025632701 TEL FAX CELL EMAIL S310N M31113H NTId #IIW2i3d $ :33d ❑ ❑ 1I0183d 3HI SV SIV AS NOLLV011ddV SIH1 oN sa,1 S310N NO1103dSNI 1VN13 AINO 3Sl 210103dSNI 210d 39Vd SIHI S310N NOI103dSNI SVD HOflO I