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HomeMy WebLinkAboutBLDG-22-002991 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 23,202'PERMIT# BLDG-22-002991 JOBSITE ADDRESS 128 ACORN HILL DR I OWNER'S NAME LIND ALAN D G OWNER ADDRESS LIND KRISTEN A 28 ACORN HILL DRIVE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL PRINT CLEARLY NEW. ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO Q 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 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❑ OTHER OF INDEMNITY!: BOND ❑ OWNERS 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 matthew scioletti LICENSE# MA SIGNATURE MP❑MGF❑JP❑ JGF❑ LPG' CI CORPORATION❑# PARTNERSHIP ❑o Lc❑# COMPANY NAME IScioletti Plumbing and Heating I ADDRESS. 158 Townhouse Ter, CITY Ihyannis (STATE MA ZIP 02601 TEL 17748100292 FAX CELL EMAIL 1 S31ON M3IARI NVld #11Wb3d $ :33d El El 1.lWa3d 3HI SV S3/AHH3S NOIld0llddd SIHl ON SOf, S310N NOI103dSNI 1YN13 AlNO 3Sf1 10103dSNI bad 3OVd SIR!. S31ON N01103dSNI SVJ HJl02!