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HomeMy WebLinkAboutBLDG-23-000912 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1k7 VI! CITY YARMOUTH MA DATE August 20,2022 PERMIT# BLDG-23-000912 JOBSITE ADDRESS 103 SWAN LAKE RD OWNERS NAME CUNNINGHAM BRIDGET E G OWNER ADDRESS CUNNINGHAM JOSEPH P 1 MERGANSER LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:0 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 1 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 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL I S31ON M3IA32!NVId #11W2i3d $ 33d 111M13d 3H1 SY S3A213S N011VOIlddV SIH1 oN seA S31ON NO1103dSNI 1VNIH AINO 3Sfl H0133dSNI eOd 30Vd SIHl S31ON NO1103dSNI SVO HOfON