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HomeMy WebLinkAboutBLDG-22-003492 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY YARMOUTH MA DATE December 22,202'PERMIT# BLDG-22-003492 L" JOBSITE ADDRESS 38 WITCHWOOD RD OWNERS NAME FECTEAU PETER L G OWNER ADDRESS GRABENBAUER SHARI 38 WITCHWOOD RD SOUTH YARMOUTH MA 02664-2909 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL En 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 0 NO 0 IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'Albert Fortin I LICENSE# 22234 SIGNATURE MP❑MOP 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: I I ADDRESS. 146 Timber Ln, CITY IMarstons Mills I STATE MA ZIP 02648 TEL I I FAX CELL 7744872919 EMAIL I I S310N M31ARI NVld #lJWN3d $ :33d ❑ ❑ 1I1,1213d 3H1 SV S3A 13S NOIlv011dd`d SIHI oN seA S31ON NOI103dSNI 1VNId /ONO 3Sf1 H0103dSNI NOd 3Jbd SIHI S310N NO11O3dSNI SVO HJfOi:I