HomeMy WebLinkAboutBLDG-22-000367 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
* = I MA DATE
July 20,2021 PERMIT# BLDG-22-000367
0 = CITY IYARMOUTH
f 1=`' OWNER'S NAME IDANFORTH RUTH A
JOBSITE ADDRESS 26 CAPT WEILER RD I
G TELI
OWNER ADDRESS DANFORTH ROBERT C 26 CAPT WEILER RD SOUTH YARMOUTH MA 02664
TYPE OR OCCUPANCY TYPE
COMMERCIAL❑ RESIDENTIAL ❑
PRINT PLANS SUBMITTED:YES El NO 0
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT: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
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE: NO El
have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
YES El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY El BOND 0
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 aall plumbing
State Plumbing dinstallations
andChapterrmdunder
the permit
Gene al Lawsfor this application will be in compliance with all Pertinent
1
f
e
provision of the Ma
SIGNATURE
PLUMBER-GASFITTER NAME Kevin Saunders LICENSE# 308 PARTNERSHIP El#�LLC 0#1 I
MP El MGF El JP El JGF 0 LPGI El CORPORATION El#L�
ADDRESS. 67 Helmsman Dr,
COMPANY NAME: SEASIDE GAS SERVICE INC TEL 5087712768
CITY Yarmouth Port STATE MA ZIP 02675
FAX
CELL 5084000943 EMAIL
S310N M
#1IW2i3d $:33d
❑ ❑ 11W213d 3HI Stl S3A213S NOIIV3IlddV SIHl /��..P Z�(, p /S?1
oN saA
S310N NO1103dSNI 1VNld JONO 3Sfl d0103dSNl NOd 3OVd SIH1
S310N N01103dSNl SVO HOf108