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HomeMy WebLinkAboutBLDG-22-002659 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK If ` r' - CITY YARMOUTH MA DATE November 09,202'PERMIT# BLDG-22-002659 JOBSITE ADDRESS 20 FORTUNE RD OWNER'S NAME RILEY PATRICK M G OWNER ADDRESS RILEY STEPHANIE M 20 FORTUNE RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO El 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 1 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 Kevin Sargent LICENSE# PL-16471-M SIGNATURE MP 0 MGF 0 JP❑ JGF❑ LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: CAPE COD GAS HEAT&NC SYSTEMS ADDRESS. 15 JAN SEBASTIAN DR,UNIT 40, CITY Sandwich STATE MA ZIP 02563 TEL 5085399303 FAX CELL 6178340785 EMAIL S31ON M3IAal NVld #LIWH3d $:333 ❑ ❑ II1A1H3d 3E11 SV S3A83S NOIlv3 lddv SIHl oN seA S31ON NO1103dSNI 1VN13 ,k1NO 3Sf1 10103dSNI?J0d 30dd SIHI S31ON NO1103dSNI SVO HOf O I