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HomeMy WebLinkAboutBLDG-22-002035 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ��_. CITY YARMOUTH MA DATE October 10,2021 PERMIT#kr BLDG-22 002035 ` JOBSITE ADDRESS 503 ROUTE 6A OWNER'S NAME WAGNER NATHAN A G OWNER ADDRESS C/O WENDELL PATRICK A 503 ROUTE 6A YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER , CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 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❑ 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 LICENSE# SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION 0#I I PARTNERSHIP 0# LLC 0#1 I COMPANY NAME: I I ADDRESS. I I CITY I I STATE I I ZIP I I TEL I I FAX I I CELL I I EMAIL I I S310N M3IA38 NVId #LIV Jd $:333 ❑ ❑ 111Al2J3d 3H1 SV SSA2J3S NOIlVOIlddV SIH1 oN saA S310N NO1133dSNI 1VNId AINO 3Sfl 80103dSNI NOd 30Bd SIH1 S310N N01103dSNI SVJ H0Il0a