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HomeMy WebLinkAboutBLDG-21-004519 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK BLDG-21-004519 TZ) CITY YARMOUTH MA DATE February 10,2021 PERMIT# ii s JOBSITE ADDRESS 300 BUCK ISLAND RD UNIT 21E OWNER'S NAME MUNDHENK CHARLES F(LIFE EST) G OWNER ADDRESS MUNDHENK KATHLEEN M(LIFE EST)15 FISHER RD HINGHAM MA 02043 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 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 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY El 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 Anthony Cooper LICENSE# 32048 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: ADDRESS. PO BOX 450, CITY Centerville STATE MA ZIP 02632 TEL 5087375348 FAX CELL 5083674487 EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES