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HomeMy WebLinkAboutBLDG-22-003509 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tI f "� CITY YARMOUTH MA DATE (December 23,2021 PERMIT# BLDG-22-003509 JOBSITE ADDRESS 31 DANAS PATH OWNERS NAME PLUMMER EDWIN F G OWNER ADDRESS PLUMMER KATHLEEN M 31 DANAS PATH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 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 I 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 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 ail Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP 0 MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#1 COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N M3IA3LI Ndld #IIW2J3d $ :33d El El 1I1/213d 3H1 SV S3/1a3S NOLLV011ddd SIHI oN saA S310N N01103dSNI 1YNId A1N0 3Sfl IO103dSNI H0d 30Vd SIH1 S310N N01103dSNI Sb'J HJla1