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HomeMy WebLinkAboutBLDG-12-00762 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ) CITY YARMOUTH MA DATE August 15,2022 PERMIT# BLDG-23-000762 JOBSITE ADDRESS 152 CAPT NOYES RD OWNER'S NAME BENJAMIN MICHAEL J G OWNER ADDRESS BENJAMIN MARY E 20 CRANBROOK RD SHREWSBURY MA 01545 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 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 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 / - /1'' (7-1,‘-2 LICENSE# SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL / d Cc_ e /'v (..)1,- .) Cc; S310N M3IA3?J NVId #1IV d $:333 ❑ ❑ 1IV d 3H1 SV S3AH3S NOIlVOIlddV SIH1 oNSA S31ON NOI!33dSNI 1VNId AINO 3Sfl 2,10103dSNI?JOd 30Vd SIHI S31ON NOLL3 dSNI SVO H0008