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HomeMy WebLinkAboutBLDG-22-004898 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [YARMOUTH MA DATE (March 05,2022 'PERMIT# BLDG-22-004898 JOBSITE ADDRESS 1210 SOUTH ST I OWNERS NAME FONTAINE LESTER E TR G OWNER ADDRESS THE L&C FONTAINE NOM TRUST 510 COTTAGE ST SPRINGFIELD MA 01104 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY O OTHER OF INDEMNITY 0 BOND 0 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❑ LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: I I ADDRESS. CITY I 'STATE ZIP TEL FAX 1 1 CELL EMAIL S310N M31A3e1 NVld #±IWel3d $ :333 ❑ 0 11161213d 3H1 SV S3A213S NOI1V011ddV SIH1 oN sad, S310N N01103dSNI 1VNl3 NINO 3Sl d0103dSNI 2l03 3OVd SIHI S310N NOI103dSNI SVO HJflO I