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HomeMy WebLinkAboutBLDG-21-000620 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11.��? CITY YARMOUTH MA DATE August 11,2020 PERMIT# BLDG-21-000620 JOBSITE ADDRESS 13&15 LORENA RD OWNER'S NAME LORENA ROAD RLTY TRUST G OWNER ADDRESS C/O ROBERT MOOREHEAD 33 GREENWOOD AVE PEMBROKE MA 02359 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 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/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:gas test 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 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 Michael Hoadley LICENSE# MA SIGNATURE MP 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: John Hoadley Plumbing&Heating ADDRESS. 672 Union St, CITY Rockland STATE MA ZIP 02370 TEL 7818788098 FAX 7818781678 1 CELL 7813891128 EMAIL S310N M3IA32i NVld #11Wi13d $ 33d ❑ ❑ 'Mad d 3H1 SY S3A213S NOI1V0llddv SIHI oNSA SALON N01103dSNI 1VNId AINO 3Sfl N0103dSNI 2:10d 3OVd SIH1 S310N N01103dSNI SVO HJflOii