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HomeMy WebLinkAboutBLDG-22-007306 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 21,2022 PERMIT# BLDG-22-007306 JOBSITE ADDRESS 39 MERCHANT AVE OWNERS NAME SMITH MARGARET E G OWNER ADDRESS 3000 TILDEN ST APT 301 WASHINGTON DC 20008-3072 TEL I 1 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El BOND ❑ 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 LICENSE# SIGNATURE MP❑MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: I I ADDRESS. I CITY I ISTATE ZIP TEL I FAX I I CELL EMAIL I S310N M31A3:1 NV1d #iIV J d $:33d 1l11033d 3H1 SV S3M3S NOIlV011ddd SIHI oN saA S310N NO1103dSNI 1VNH A1N0 3Sfl 210103dSNI 2I03 3OVd SIR! S3 LON NOI103dSNI SYJ HOfOd