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HomeMy WebLinkAboutBLDG-22-003487 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '-s CITY YARMOUTH MA DATE December 21,202'.PERMIT# BLDG-22-003487 -��• JOBSITE ADDRESS 46 MINNETUXET WAY OWNER'S NAME BASLER BRIAN D G OWNER ADDRESS P 0 BOX 119 YARMOUTH PORT MA 02675-0119 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 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 1 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:outdoor generator 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 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 as 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 Christopher Gilligan LICENSE# 30706 SIGNATURE MP❑MGF❑JP©' JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Gilligan Plumbing and Heating ADDRESS. 320 Mayfair Road, CITY South Dennis STATE LMA ZIP 02660 TEL 5082212699 FAX CELL EMAIL S31ON M3IA32i NVld #±IW2:13d $ :33d El El lJ11M3d 3Hl SV S3A213S NOIlV011ddV SIHl oN saA S310N NO1133dSNI lYNId AlNO 3Sl 2:10103dSNI dOd 30Vd SIR]. S31ON N01103dSNI SYJ HOflO