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HomeMy WebLinkAboutBLDG-22-003172 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kz: ' CITY YARMOUTH MA DATE December 03,202'PERMIT# BLDG-22-003172 JOBSITE ADDRESS 16 GREEN TEAL WAY OWNER'S NAME WEISSBERGER EDWARD G OWNER ADDRESS WEISSBERGER RUTH M 16 GREEN TEAL WAY YARMOUTH PORT MA 02675-1250 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES D 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 FRYOLATOR FURNACE 2 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 at 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 Kevin Saunders LICENSE# 308 SIGNATURE MP❑MGF❑JP 0 JGF❑ LPG! 0 CORPORATION❑# J PARTNERSHIP ❑# Inc❑# COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768 FAX CELL 5084000943 EMAIL S2ION M31A32:1 NV-1d #JJWb3d $ :33d 11M3d 3H1 SV S3AH3S NOI1VDIlddV SIH1 oN saA S310N NO1133dSNl 1VNId A1NO 3Sfl 2:10133dSNI 2:1Od 30Vd SIH1 S310N NO1133dSNI S O HOf1a1