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HomeMy WebLinkAboutBLDG-22-001191 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lk,,, CITY YARMOUTH MA DATE September 01,202 PERMIT# BLDG-22-001191 tl A• JOBSITE ADDRESS 31 PARKWOOD RD OWNER'S NAME GUIDERA BARBARA L TR G OWNER ADDRESS BARBARA L GUDIERA REV TRUST 21 PARKWOOD RD SOUTH YARMOUTH MA TEL 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 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 1 . DIRECT VENT HEATER , DRYER , FIREPLACE 1 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 1 OTHER 1 OTHER DESCRIPTION:1 gas generator INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ 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 Wellington Farias LICENSE# 15949 SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: Wellington Plumbing&Heating,Inc. ADDRESS. 71 Vernon Street, CITY Rockland STATE MA ZIP 02370 TEL FAX CELL 7815897578 EMAIL S31ON M3IA321 NVId #1IV J3d $:33d fD zZ/p/J? ❑ ❑ 1111213d 3H1 SV S3a13S NOIlVOIIddV SIHJ oN seA S31ON NOI103dSNI 1VNId AINO 3sn NO103dSNI dOd 3OVd SIHl S310N NO1133dSNI SVS HOf10d