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HomeMy WebLinkAboutBLDG-22-007411 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ve, CITY 'YARMOUTH —1 MA DATE [June 24,2022 PERMIT# BLDG-22-007411 �fy�Y JOBSITE ADDRESS 122 HOCKANOM RD 1 OWNER'S NAME VANBAARS JOHN G OWNER ADDRESS VANBAARS LINDA J 22 HOCKANOM RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:© REPLACEMENT.❑ PLANS SUBMITTED:YES❑ NO El 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 1 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 El NO El IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY CI BOND El 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❑MGF❑JP❑ JGF❑ LPG!0 CORPORATION❑# PARTNERSHIP ❑o LLC❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N M3IA321 NYld #111/M3d $ :333 ❑ ❑ 111N213d 3H1 S`d S3A1:13S NOI1V011dd`d SIHl oN SGA S310N NOI103dSNI 1VNl3 KINO 3Sl 210103dSNI 2103 30Vd SIHI S310N N01103dSNI St/9 H0f1021