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HomeMy WebLinkAboutBLDG-22-003475 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w CITY YARMOUTH MA DATE December 21,2021 PERMIT# BLDG-22-003475 rlf JOBSITE ADDRESS 7 OUT OF BOUNDS DR OWNERS NAME REYNOLDS THOMAS E G OWNER ADDRESS REYNOLDS GRACE M 7 OUT OF BOUNDS DR SOUTH YARMOUTH MA 02664-2040 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: m 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 1 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 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 Stephen Roberts LICENSE# 5104 SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME ADDRESS. 17 lake dr, CITY Plymouth STATE MA ZIP 02360 TEL FAX CELL 5086480900 EMAIL S310N M3U13H NV1d #iftN 9d $ :33d El ❑ 1114182d 3H1 SV SaA 13S NOLLVO lddV SIHJ oN seA S310N N01133dSNl1VNId /ONO 3Sf O103dSNI NOd 3OVd SIHl S310N N01133dSNI SVO HJflOZI