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HomeMy WebLinkAboutBLDG-22-003735 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I' - CITY YARMOUTH MA DATE January 05,2022 PERMIT# BLDG-22-003735 t JOBSITE ADDRESS 25 LUCERNE DR OWNERS NAME VANLENNEP WILLIAM B G OWNER ADDRESS VANLENNEP SUSAN P 0 BOX 211 PEPPERELL MA 01463 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES El NO El FIXTURES FLOORS BSM 1 2 3 4 5 6 7 B 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❑ 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 LICENSE# SIGNATURE MP❑MGF El JP El JGF❑ LPGI El CORPORATION❑it PARTNERSHIP ❑# LLC El# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N M3IA32i N`dld #iJt J JJd $:33d ❑ ❑ ANN3ci 3H1 SV S3A2i3S NOI1VOIlddV SIR! oN saA S310N NOI103dSNI 1VNld JIINO 3S11210103dSNI 210d 3OVd SIHI S31ON NOI103dSNI SYO HJf1021