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HomeMy WebLinkAboutBLDG-22-000406 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK A! CITY YARMOUTH MA DATE July 22,2021 PERMIT# BLDG-22-000406 JOBSITE ADDRESS 9 BELLE OF THE WEST RD OWNER'S NAME EVANS KENNETH M G OWNER ADDRESS EVANS CHRISTINA L 9 BELLE OF THE WEST RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 1-2 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❑ 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 keith famham LICENSE# 11601 SIGNATURE MP El MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: South Shore Heating&Cooling ADDRESS. 57,Whites Path, CITY South Yarmouh STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL S3.LON M3IA32J NVId #1IW213d $:33d ❑ ❑ 111Ni13d 3H1 SV S3Aa3S NOI1VOIlddV SIR! oN seA S31ON NO1103dSNI 1VNId AINO 3Sl 210103dSNI 2JOd 39Vd SIH! S3.LON NOI133dSNl SVO HSf102i