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HomeMy WebLinkAboutBLDG-22-000954 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 46 CITY YARMOUTH MA DATE (August 19,2021 PERMIT A BLDG-22-000954 JOBSITE ADDRESS 481 BUCK ISLAND RD UNIT 14FC OWNER'S NAME LMSHIRE DAVID G G OWNER ADDRESS HAMSH IRE MARY ANN 481 BUCK ISLAND RD #14F WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL LI RESIDENTIAL El PRINT CLEARLY NEW: © RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 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 © 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❑JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. 17lake dr, CITY Plymouth STATE MA ZIP 02360 TEL FAX CELL 5086480900 EMAIL S310N M3IA32I Ndld #±IW2:13d $ :33d 15;7)'z t—PO ❑ ❑ 1111213d 3H1 SV S3/1213S NOLLVOIlddV SIHI oN seA S31ON NO1103dSNI lt/NId KINO 3Sl 2H0103dSNI 2iOd 30Vd SIHI S310N NO1103dSNI SVO HDflO