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HomeMy WebLinkAboutBLDG-22-003845 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w' CITY YARMOUTH MA DATE January 10,2022 PERMIT# BLDG-22-003845 II.=f JOBSITE ADDRESS 34 ARROWHEAD DR OWNER'S NAME SOLOMON STEVEN F G OWNER ADDRESS SOLOMON ELIZABETH F 34 ARROWHEAD DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: © RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO III 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER r 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 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 Stephen Roberts LICENSE E 5104 SIGNATURE MP El MGF El JP El JGF El LPGI El CORPORATION 0# PARTNERSHIP ❑# LLC El# COMPANY NAME: ADDRESS. 17 lake dr, CITY Plymouth STATE MA ZIP 02360 TEL FAX CELL 5086480900 EMAIL S310N M9U13b NVld #iIIN2i3d $ :33d 111A1213d 3H1 SV S3A DS SIHl oN se), S310N N01103dSNI 1VNId A1NO 3Sfl IOIO3dSNI :1Od 3OVd SIHl SiLON NO1103dSNI SVO HDflO