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HomeMy WebLinkAboutBLDG-22-007133 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' CITY YARMOUTH MA DATE June 09,2022 PERMIT# BLDG-22-007133 1 JOBSITE ADDRESS 12 MARSH SIDE DR OWNERS NAME WALD JAN DAVID TRS G OWNER ADDRESS WALD DONNA MARIE TRS 12 MARSH SIDE DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ 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 DIRECT VENT HEATER _ DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR 1 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 1 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 LABILITY 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 Randall Agnew LICENSE# 17492 SIGNATURE MP 0 MGF❑JP 0 JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RANDALL C AGNEW ADDRESS. 1381 OLD FALMOUTH RD, CITY MARSTONS MILLS STATE MA ZIP 026481555 TEL FAX CELL EMAIL I S31ON M3IA321 NHId #±I 4 3d $:333 El El 1I1A213d 3H1.SV S3/1213S NOLLV011ddd SIHI oN seA S310N NOI103dSNI 1VNId /LINO 3Sf1 W10103dSNI ZI03 39Vd SIHJ S310N NO1103dSNI SY9 HDflO I