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HomeMy WebLinkAboutBLDG-22-003401 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY YARMOUTH MA DATE 'December 15,2021 PERMIT# BLDG-22-003401 JOBSITE ADDRESS 32 MORNING DR OWNER'S NAME MATHESON LILLIAN G G OWNER ADDRESS 128 GINGERBREAD LN YARMOUTH PORT MA 02675-1109 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES El NO El 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 1 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El BOND 0 OWNERS 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 Fernando Coelho LICENSE# 34508 SIGNATURE MP 0 MGF❑JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑H LLC❑H COMPANY NAME: ADDRESS. 16 Wildwood Path, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL fernando252c(a�gmail.com S31ON M3IARH NVld #lJWb3d $ :33J ❑ ❑ 1114N3d 3H1 SV S3A213S N011VOIlddv SIHl oN saA S310N NOI103dSNI 1VNIJ A-NO 3Sfl 0103dSNI HOI 3OVd SIHI S310N NO1103dSNI SVD HJl0H