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HomeMy WebLinkAboutBLDG-22-004559 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 16,2022 PERMIT# BLDG 22-004559 Ian<: JOBSITE ADDRESS 52 PRINCE RD OWNER'S NAME PIERCE BARBARA J G OWNER ADDRESS 52 PRINCE RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ • 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 1 FRYOLATOR . FURNACE 1 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 1 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 0 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 Ryan White LICENSE# 16068 SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. P.O.Box 425, CITY Harwich STATE MA ZIP 02645 TEL FAX I I CELL EMAIL S31ON M31A321 NVId #1IW213d $'33d ❑ ❑ 11M3d 3H1 SV S3AH3S N011V Ilddtl SRL oN seA S310N NO1103dSNI 1VNld AINO 3Sfl 210103dSNl 2JOd 3OVd SIHI S310N NO1103dSNl SVO HJl021