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HomeMy WebLinkAboutBLDG-22-003639 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 29,202'PERMIT# BLDG-22-003639 JOBSITE ADDRESS 1120 BAKERS PATH I OWNER'S NAME SULLIVAN PAUL J JR G OWNER ADDRESS 120 BAKERS PATH SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES El NO El 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: 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 El 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 Sean Hanrahan LICENSE# 15822 SIGNATURE MP©MGF El JP 0 JGF El LPGI El CORPORATION El# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. PO box 688, CITY Centerville STATE MA ZIP 02632 TEL FAX CELL 17742380286 1 EMAIL __J S31ON M3IAal NVld #1I1Al2j3d $ :33d El El 111Al2l3d 3H1 SV S3A213S NOLLVOIlddd SIHl oN saA S3ION NO1103dSNI IVNId ICING 3Sf1 Z10103dSNI 210d 39dd SIHI S310N NO1103dSNI SVO H9f1O2:I