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HomeMy WebLinkAboutBLDG-22-002279 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -'� CITY IYARMOUTH I MA DATE 'October 20,2021 'PERMIT# BLDG-22-002279 l JOBSITE ADDRESS 24 KATES PATH VILLAGE OWNER'S NAME WARREN ANN R TR G OWNER ADDRESS ANN R WARREN LIVING TRUST 9 FORBES PL#109 DUNEDIN FL 34698 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ 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 _ _ GENERATOR _ GRILLE _ INFRARED HEATER _ LABORATORY COCKS _ - _ MAKEUP AIR UNIT OVEN - POOL HEATER - ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER OTHER I 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 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 ❑ 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 he in compliance with all Pertinent provision of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Eric Whiteley LICENSE# Massachusetts SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: W Vernon Whiteley ADDRESS. PO Box 1266, CITY West Chatham STATE MA ZIP 02669 _I TEL 5089451100 FAX CELL EMAIL S310N M31A3d NVld #±IW2I d $ :33d ❑ ❑ 111Al2:13d 3H1 SV S3A 3S NOI1VOIldd`d SIHl ON SaA S310N NO1153dSNI lYNId AlNO 3Sl el0103dSNI ZIOd 90Vd SIHI S310N NO11J3dSNI SVe HE flO