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HomeMy WebLinkAboutBLDG-22-006492 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '^ �$ CITY 'YARMOUTH I MA DATE IMay 11,2022 I PERMIT# BLDG-22-006492 JOBSITE ADDRESS 66 HOMERS DOCK RD OWNER'S NAME IGLODIS PATRICIA A G OWNER ADDRESS 66 HOMERS DOCK RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL©' PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY 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 (John English I LICENSE# 16764 SIGNATURE MP El MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: I I ADDRESS. 132 Winslows Drive,Mashpee,MA, CITY IMASHPEE,MA ISTATE MA ZIP 02649 TEL I FAX CELL I EMAIL I S310N M3IA32i NVld #lIIJ d $ :33d 111A2l3d 31-11 SY S3A213S NOI1d01ldd`d SIHl oN saA S31ON NOI103dSNI 1VNId AlNO 3Sfl O.L33dSNI 210d 3OVd SIHI S310N NO1103dSNI SYJ HOflO