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HomeMy WebLinkAboutBLDG-22-003504 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 23,202`.PERMIT# BLDG-22-003504 I I JOBSITE ADDRESS 12 TASMANIA DR OWNERS NAME VAN WICKLE GLENN C G OWNER ADDRESS VAN WICKLE SHARON M 12 TASMANIA DR YARMOUTH PORT MA 02675-2156 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO El FIXTURES FLOORS—+ BBM 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 1 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY 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 Keith Farnham LICENSE# MA SIGNATURE MP El MOP 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑H LLC❑ COMPANY NAME: SouthShore Heating 8 Cooling ADDRESS. 57,Whites Path,Whites Path.Whites Path,Whites Path, CITY South Yarmouth STATE MA ZIP 02644 TEL 5083986901 FAX CELL EMAIL S310N M3IA38 NVld #11Wb3d $ :33d ❑ ❑ 1111\183d 3Hl SV S3AH3S NOI1V3IlddV SIHI ON SO), S310N NO1103dSNI 1VNId AlNO 3Sl 210103dSNI 2JOd 3OVd SIHI S310N NO1133dSNI SVO HJl0H