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HomeMy WebLinkAboutBLDG-22-004982 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE (March 09,2022 I PERMIT# BLDG-22-004982 $, JOBSITE ADDRESS 150 ASTOR WAY I OWNER'S NAME MONTEIRO LUISA G OWNER ADDRESS 50 ASTOR WAY SOUTH YARMOUTH MA 02664 I TELI TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 111 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 1 _ 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: —1 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 at 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 Femando Coelho LICENSE# [34508 SIGNATURE MP❑MGF❑JP© JGF❑ LPG( ❑ CORPORATION❑#L PARTNERSHIP ❑# LLC❑# COMPANY NAME ADDRESS. 16 Wildwood Path, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL femando252c ..omail.com S31ON M3IA3ZI Ndld #1IWZl3d $ :333 ❑ ❑ JI01213d 3H1 SV S3A2i3S NOI1VOIlddV SIH1 oN saA S31ON N01103dSNI 1VNId AlNO 3Sfl 210103dSNI?:I0J 30Vd SIHI S310N NO1103dSNI SVO HOflO I