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HomeMy WebLinkAboutBLDG-17-00323 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 19, 2 PERMIT# BLDG-17-003233 JOBSITE ADDRESS 300 BUCK ISLAND RD UNIT 4C OWNER'S NAME GOODWIN GEORGE W G OWNER ADDRESS GOODWIN GRETCHEN M 300 BUCK ISLAND RD UNIT 4C WEST TEL YARMOUTH MA 02673 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL D PRINT CLEARLY NEW ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • _ MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: building empty for over a year gas company requires test INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES © NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER OF INDEMNITYD 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 william fitzgerald LICENSE# 12912 SIGNATURE MPD MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: mr plumb rite ADDRESS 341 pine st, CITY centerville STATE MA ZIP 02632 TEL 5087710836 FAX r CELL EMAIL \ � I \\�