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HomeMy WebLinkAboutBLDG-22-004362 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -- i BLDG-22-004362 CITY YARMOUTH MA DATE February07,2022 PERMIT# JOBSITE ADDRESS 23 GOLFERS CIR OWNER'S NAME SMITH ANN MARIE T G OWNER ADDRESS SMITH PAUL F 23 GOLFER'S CIR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO El FIXTURES FLOORS—I 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 El 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 Michael Donovan LICENSE# Massachusetts SIGNATURE MP El MGF El JP El JGF El LPGI El CORPORATION El# PARTNERSHIP ❑# LLC El# COMPANY NAME: ADDRESS. 135 Captain Small Rd, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL 7749941894 EMAIL S310N M3IA321 NVId #1IVdH1d $ 333 0 ❑ IIVOnd 3H1 SV S3fH3S NOI1VOIlddV SIHl oN s0A S310N N01103dSNI IVNId AINO 3Sfl H0103dSNI 2i0d 3OVd SIHl S310N N01103dSNI SVO HOf1021