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HomeMy WebLinkAboutBLDG-22-007293 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 20,2022 PERMIT# BLDG-22-007293 It, JOBSITE ADDRESS 101 CAPT YORK RD OWNER'S NAME ALLEN DAVID W G OWNER ADDRESS ALLEN DEBORAH M 101 CAPT YORK RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 111 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 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 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 LABILITY INSURANCE POLICY© OTHER OF INDEMNITY ID 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 State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'Glenn Sherman I LICENSE# I20921 SIGNATURE MP❑MGF❑JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# ILLC❑# COMPANY NAME: 'New England Plumbing Services I ADDRESS. 120 Deacons Folly Rd, CITY 'Harwich I STATE MA ZIP 02645 TEL 17742090410 FAX I I CELL I I EMAIL ' S310N M3IA32J NV'ld #.I1/0:13d $ :33d ❑ 0 1I N 3d 341 SV S311213S NOI1V011ddb SIHl oN seA S310N NOI103dSNI 1VNId AlNO 3Sfl H0103dSNI 210d 3OVd SIHl S2ION N01103dSNI SVO HOf102i