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HomeMy WebLinkAboutBLDG-22-004570 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE IFebruary 16,2022 I PERMIT# BLDG-22-004570 JOBSITE ADDRESS 24 FREEMAN RD OWNER'S NAME MARTIN MARGUERITE T G OWNER ADDRESS 24 FREEMAN RD YARMOUTH PORT MA 02675 TEL -TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED:YES❑ 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 I 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 0 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 Phillip Durfee LICENSE# L3774 1 SIGNATURE MP❑MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: ADDRESS. 12 Bertram ave, CITY South Dennis STATE MA ZIP 02660 TEL FAX CELL EMAIL • S310N M3IA32i NVId #IIW2i3d $ :333 ❑ ❑ II1A1a3d 3H1 SV S3A213S NOI1VOIlddV SIHJ oN sa,. S310N NO1103dSNI IVNId AlNO 3Sfl eloioadsm 2iOd 39Vd SIHI S31ON NO1103dSNI WO H9flO