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HomeMy WebLinkAboutBLDG-22-006519 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK VICITY 'YARMOUTH I MA DATE (May 12,2022 IPERMIT# BLDG-22-006519 JOBSITE ADDRESS 22 SETUCKET RD OWNER'S NAME VARJIAN KATHRYN G OWNER ADDRESS PO BOX 216 CENTERVILLE MA 02632 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑ 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 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 Randall Agnew LICENSE# 17492 SIGNATURE MP❑MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RANDALL C AGNEW ADDRESS_ 381 OLD FALMOUTH RD, CITY MARSTONS MILLS STATE MA ZIP 1026481555 TEL FAX I CELL EMAIL S31ON M3IA32f Ndld #.IIN:13d $ :33d ❑ ❑ 111%13d 3H1 SV S3AH3S N011V011ddV SIHJ ON SeA S310N NO1103dSNI l'dNI AlNO 3Sf1?J(1103dSNI 21Od 3OVd SIHl S31ON NOI103dSNI SVO HJfOa