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HomeMy WebLinkAboutBLDG-22-007264 Unit C4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4( 1) CITY YARMOUTH MA DATE June 16,2022 PERMIT# BLDG-22-007264 JOBSITE ADDRESS 21 FRUEAN AVE UNIT C4 OWNER'S NAME ELKINS WILLIAM TRS G OWNER ADDRESS ELKINS MYRNA L TRS 84 ROLLING HITCH ROAD CENTERVILLE MA 02632 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 GENERATOR 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:pressure test to reactivate the gas system 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 El 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 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 brian hibbard LICENSE# 11977 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: cape cod plumbing and heating inc ADDRESS. po box 429, CITY south dennis STATE MA ZIP 02660 TEL 5083982228 FAX CELL EMAIL S31ON M3IA32J NVId #1IW?J3d $ 33d ❑ ❑ 1.1Vkl3d 3HI SY SIAN3S NOIlVOIIddV SIHI oN seA S310N NO1103dSNI 1VNId AINO 3Sfl 2l0103dSNI 210d 30Vd SIHI S310N NO1103dSNI SVO HOf1Od