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HomeMy WebLinkAboutBLDG-21-005024 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH-V MA DATE March 07,2021 PERMIT# BLDG 21 005024 ►-f�,. r �,• � = JOBSITE ADDRESS 74 WILFIN RD OWNER'S NAME RUBIN BLAKE J G OWNER ADDRESS RUBIN LORRAINE D 23 BRICE CIR HOLDEN MA 01520 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El 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 1 , 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 1 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 0 JP❑ JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES