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HomeMy WebLinkAboutBLDG-22-004015 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . S CITY YARMOUTH MA DATE January 20,2022 PERMIT# BLDG-22-004015 JOBSITE ADDRESS 149 HAYWOOD AVE I OWNER'S NAME WILSON KIM M G OWNER ADDRESS 49 HAYWOOD AVE SOUTH YARMOUTH MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW El RENOVATION:© REPLACEMENT:El PLANS SUBMITTED:YES El NO El 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY El BOND El 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 'briar;hibbard I LICENSE# 11977 SIGNATURE MP El MGF❑JP El JGF 0 LPGI El CORPORATION El# PARTNERSHIP ❑# LLC❑# COMPANY NAME: I I ADDRESS. Ipo box 429, CITY 'south dennis I STATE MA ZIP 02660 TEL 15083982228 I FAX 1 1 CELL 1 I EMAIL I S310N M31Aal Ndld #JJINH3d $ :33d 0 111NRJ3d 3141 SV S3A13S NOLLVO ldd`d SIHJ oN saA S310N N01103dSNI 1VNId /LINO 3Sfl JO109dSNI H03 3OVd SIHl S310N NOI103dSNI SVD HOflO