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HomeMy WebLinkAboutBLDG-22-007345 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE 'June 22,2022 I PERMIT# BLDG-22-007345 JOBSITE ADDRESS LO FRANKLIN ST EXT OWNERS NAME COTELL ROBERT D(EST OF) G OWNER ADDRESS CIO COTELL DAN 3069 ENTERPRISE RD LEXINGTON NC 27295 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 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 1 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 0 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 LICENSE It SIGNATURE MP❑MGF❑JP 0 JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: I I ADDRESS, I CITY I I STATE ZIP I I TEL I FAX CELL I I EMAIL I S3 LON M31AJH NYYld #11Wb3d $:33d 0 0 111/M3d 3111 SV S3A2:13S NOI1VOIlddd SIHI ON SeA S310N N01103dSNI 1VNH NINO 3Sfl 210103dSNI 2lOd 3OVd SIHI SRION NOI103dSNI SVO HOf102I