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HomeMy WebLinkAboutBLDG-22-006272 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r; CITY YARMOUTH MA DATE IMay 02,2022 I PERMIT# BLDG-22-006272 II_ ' JOBSITE ADDRESS 61 OUT OF BOUNDS DR OWNERS NAME CAFFREY PATRICIA E G OWNER ADDRESS 61 OUT OF BOUNDS DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:CI PLANS SUBMITTED:YES El NO El 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 I 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 El 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 ❑ 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 0 MGF❑JP❑ JGF❑ LPG'0 CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. CITY STATE ZIP 1 TEL FAX CELL EMAIL S310N M9IA3d Ndld #.IW213d $ :333 ❑ ❑ 1IW213d 3H1 SV S3/12H3S NOI1VZIlddV SIHl oN saA S310N NOI103dSNI 1VNId AINO 3Sf12i0103dSNI 2i0d 39Vd SIH1 S310N NOI103dSNI SVD HOflO I