Loading...
HomeMy WebLinkAboutBLDG-22-005004 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t � � CITY YARMOUTH 11 MA DATE March 10,2022 PERMIT# BLDG-22-005004 JOBSITE ADDRESS 18 PINE GROVE VILLAGE OWNER'S NAME KIRKPATRICK JOHN _ G OWNER ADDRESS C/O ANDREW DIAMOND 18 PINE GROVE VILLAGE YARMOUTH PORT MA 02675 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 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/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 El 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 Kenneth Duarte LICENSE# 11012 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG] ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS 37 collins ave, CITY Centerville STATE MA ZIP 02632 TEL FAX CELL EMAIL S310N M3IA321 NVId #1ftN d $•33d 11VC3d 3E11 SV S3A2J3S NOI1VOIlddV SIHl oN saA S31ON NOI103dSNl 1VNld AINO 3Sfl N0103dSNI dOd 30Vd SIHI S310N NOI103dSNI SVO HOflO