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HomeMy WebLinkAboutBLDG-22-000283 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH ki MA DATE July 16,2021 PERMIT# BLDG-22-000283 C( r=sT JOBSITE ADDRESS 182 DIANE AVE OWNER'S NAME PETRIE BARBARA F G OWNER ADDRESS 344 DEPOT ST DENNISPORT MA 02639 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ 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 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 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❑ 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 Kevin Sargent LICENSE# PL-16471-M SIGNATURE MP 0 MGF © JP❑ JGF❑ LPG] 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Cape Cod Gas Heat&AC Systems ADDRESS. 15 JAN SEBASTIAN DR,UNIT 4D, CITY Sandwich STATE MA ZIP 02563 TEL 5085399303 FAX 5088339383 CELL 6178340785 EMAIL S310N M31A321 NVld #1101213d $:33d ❑ ❑ 111NH3d 3E11 SV S3ANSS NOI1v011ddV SIHI ON SOA S310N N01103dSNI IVNId ,LINO 3Sfl a0103dSNI 1:10d 30Vd SIH1 S310N N01103dSNI SVO HJl0a