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HomeMy WebLinkAboutBLDG-22-003430 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �_ CITY YARMOUTH MA DATE 'December 16,202''PERMIT# BLDG-22-003430 JOBSITE ADDRESS [15 GANNET RD I OWNER'S NAME SULLIVAN KEVIN P G OWNER ADDRESS SULLIVAN ELAINE C 14 POTTER CIR NORTHBORO MA 07532 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 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 -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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'Cameron Natale I LICENSE# IMA I SIGNATURE MP❑MGF Q JP❑ JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC 0 A COMPANY NAME: 'Robies 'ADDRESS. 1200 Audrevs Lane, CITY 'Marstons Mills 'STATE MA ZIP 102648 'TEL I FAX 15085341272 'CELL 17743537354 1 EMAIL ' S310N M3IA9H NV1d #llL'N d $ :33d El El 111A213d 3H1 SV S3A2j3S NOI1`d3llddd SIH1 oN saA S31ON NOIlO3dSNI IVNId AlNO 3Sf1 ZI0133dSNI HOd 3OVd SIHl S31ON NOI133dSNl S` O HOflOH