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HomeMy WebLinkAboutBLDG-22-004338 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK wn CITY YARMOUTH MA DATE February04,2022 PERMIT# BLDG-22-004338 r JOBSITE ADDRESS 51 BRADFORD RD OWNER'S NAME MILLS JEANNETTE AMATO G OWNER ADDRESS MILLS GARY J 20 MONADNOCK RD ARLINGTON MA 02174-8001 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ 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/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 LICENSE# SIGNATURE MP 0 MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. CITY I STATE ZIP TEL FAX CELL EMAIL S310N M3IA32i NVld #.I1Ab3d $ :33d 11WHal 3H1 SV S3NES N011vOIldd`d SIH. oN S8A S31ON NOI103dSNI 1VNId AINO 3Sf1?:10103dSNI HOd 39dd SIHI S310N N01103dSNI SVD HO11OH