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HomeMy WebLinkAboutBLDG-22-004085 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r-101 CITY YARMOUTH MA DATE January 24,2022 PERMIT# BLDG-22-004085 JOBSITE ADDRESS 7 WINCHESTER CT OWNER'S NAME MORGAN JOSEPH F G OWNER ADDRESS MORGAN MARY ELLEN 29 PHEASANT ST WEST ROXBURY MA 02132-3011 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 1 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/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 Michael Maille LICENSE# 11355 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: HomeServe USA Energy Services NE LLC ADDRESS. 5 Constitution Way. CITY Woburn STATE MA ZIP 01801 TEL FAX CELL 7813592620 EMAIL S310N M3IA321 NVId #1I01213d $:333 ❑ ❑ 1IIld3d 3Hl SV S3A213S NOIiV011ddtl SIHl oN seA S310N NO1103dSNI TVNId AINO 3Sfl 10103dSNI 210J 30Vd SIHl S310N NO1133dSNI SV0 HOflOa