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HomeMy WebLinkAboutBLDG-22-005723 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK te CITY 'YARMOUTH I MA DATE April06,2022 1 PERMIT# BLDG-22-005723 JOBSITE ADDRESS 1300 BUCK ISLAND RD UNIT 13L I OWNER'S NAME NELSON SANDRA J G OWNER ADDRESS 300 BUCK ISLAND RD 13L WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: El RENOVATION:❑ 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 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 ❑ NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El 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 'Stephen Roberts I LICENSE# 15104 SIGNATURE MP❑MGF 0 JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑41 ILLC 0# COMPANY NAME: ADDRESS. 17 lake dr, CITY Plymouth STATE MA ZIP 02360 TEL FAX CELL 5086480900 EMAIL S310N M3IA32:1 NVld #1IV 2d $ :33d ❑ ❑ 1111t13d 3H1 Sd S3At13S NOI1VOIlddV SIR1 oN saA S310N N011O3dSNI lYNId AINO 3Sfl 1:10103dSNI ZIOd 3OVd SIHI S310N NOI103dSNI SVO HOf O I