HomeMy WebLinkAboutBLDG-22-007114 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
If_° CITY YARMOUTH J MA DATE 'June 08,2022 1 PERMIT# BLDG-22-007114
JOBSITE ADDRESS 49 SHAKER HOUSE RD OWNER'S NAME SISSENS BERNARD J
G OWNER ADDRESS SISSENS CLARE J 49 SHAKER HOUSE RD YARMOUTH PORT MA 02675-1927 TEL l
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ 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 I 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❑ 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 IDimosthenis Kapoukranidis 'LICENSE# 34414 SIGNATURE
MP❑MGF❑JP El JGF El LPGI El CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME: ' 'ADDRESS. 19 Adams Rd,
CITY 'West Yarmouth I STATE MA ZIP 02673 TEL '
FAX CELL I 'EMAIL '
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