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HomeMy WebLinkAboutBLDG-22-004967 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ( CITY YARMOUTH MA DATE March 08,2022 PERMIT# BLDG 22 004967 rr JOBSITE ADDRESS 75 CURVE HILL RD OWNERS NAME CANNING ROBERT J G OWNER ADDRESS CANNING LAURIE J 75 CURVE HILL ROAD SOUTH YARMOUTH MA 02664-2104 TEL r TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 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 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 0 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# SIGNATURE MP 0 MGF ❑ JP 0 JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL I S310N M31A321 NVId #11012i3d $:333 ❑ ❑ 111N83d 3E11 SV S3A i3S N011V3IlddV SIHI ON SSA S310N NO1103dSNI lVNld AlNO 3Sfl 210103dSNI HOd 3OVd SIHI S310N NO1103dSNI SVO HJl0H