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HomeMy WebLinkAboutBLDG-23-001089 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'August 30,2022 PERMIT# BLDG-23-001089 JOBSITE ADDRESS 5 OAK GLEN VILLAGE OWNER'S NAME LECLAIR-ROBBINS DENISE TR G OWNER ADDRESS C/O TIM JOHNSON SOAK GLEN VILLAGE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT.❑ PLANS SUBMITTED:YES El 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 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 0 NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY INSURANCE POLICY© OTHER OF INDEMNITY❑ 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 at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Roberts LICENSE# 5104 SIGNATURE MP El MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. 17 lake dr, CITY Plymouth STATE MA ZIP 02360 TEL FAX CELL 5086480900 EMAIL S310N M3IARI NVId #llV 2d $:33d 1IWH3d 3H1 SV S3M3S NOLLVOIlddV SIHI oN seA S31ON NO1103dSNI 1VNId VINO 3Sl 2l0103dSNI 210d 3OVd SIH1 S310N NOI103dSNI SVO H9f1a1