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HomeMy WebLinkAboutBLDG-22-006533 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE May 13,2022 PERMIT# BLDG-22-006533 JOBSITE ADDRESS 24 CROWELL RD OWNER'S NAME HOUSTON THOMAS C G OWNER ADDRESS 24 CANOE RIVER RD SHARON MA 02067-2977 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 2 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❑ 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 Kevin Saunders LICENSE# 308 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768 FAX CELL 5084000943 EMAIL S310N M3IA31:1 NVId #1ft'J d $ 33d El ❑ 111NH3d 3H1 SV S3A213S N011V01lddV SIH1 oN seA S31ON NO1103dSNI 1VNId AINO 3Sfl H0103dSNI HOd 30Vd SIHI S310N NO1103dSNI SVO H000H