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HomeMy WebLinkAboutBLDG-22-000682 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 CITY YARMOUTHik, l MA DATE August 06,2021 PERMIT# BLDG•22 000682 If JOBSITE ADDRESS 162B PLEASANT ST OWNER'S NAME ACHESON DAVID C LIFE EST G OWNER ADDRESS 800 25TH ST NW APT 706 WASHINGTON DC 20037-2208 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: m 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 FRYOLATOR FURNACE GENERATOR 1 GRILLE • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/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❑ 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 Eric Whiteley LICENSE# Massachusetts SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: WV Whiteley ADDRESS. 28 Village Landing, CITY West Chatham STATE MA ZIP 102669 I TEL 15089451100 I FAX CELL I I EMAIL 1 I S310N M31AMN NVId #11W213d $ 333 0 0 11W$3d 3H1 Stl S3A83S NOI1VOIlddV SIHI oN saA S310N NO1103dSNI 1VNId AINO 3Sfl bO103dSNI :10J 39Vd SIH1 S31ON NO1103dSNl SVO HOf108