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HomeMy WebLinkAboutBLDG-22-007017 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4 (6 CITY YARMOUTH MA DATE June 05,2022 PERMIT# BLDG-22-007017 JOBSITE ADDRESS 18 POWERS LN OWNER'S NAME GREAT ISL HOMEOWNERS ASSOC INC G OWNER ADDRESS PO BOX 684 WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: © RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 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 1 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 © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 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 LICENSE# SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC El# COMPANY NAME: ADDRESS. CITY STATE ZIP I I TEL I FAX CELL EMAIL I S310N M3IA32!NVId #111N2J3d S:33d 1IV d 3H1 SV S3ALI3S NOIiVOIlddV SIH1 ON seA S310N NOI1O3dSNI 1VNId AINO 3Sfl b0103dSNI 2lOd 3OVd SIHI S31ON NO1103dSNI SVO HJl02!