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HomeMy WebLinkAboutBLDG-23-001602 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH J MA DATE (September 27,2021 PERMIT# BLDG-23-001602 JOBSITE ADDRESS 4 ORCHID LN OWNERS NAME CHILDS MATTHEW L G OWNER ADDRESS CHILDS HEATHER A 4 ORCHID LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 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/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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY 0 BOND ❑ OWNERS 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 Imatthew scioletti I LICENSE# MA SIGNATURE MP 0 MGF❑JP❑ JGF El LPG! El CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: I I ADDRESS. 158 townhouse ter, CITY Ihyannis ISTATE MA ZIP 02601 TEL 17748100292 FAX CELL I IEMAIL I S310N M3IA32i Mild #llWb3d $ :33d ❑ El iIYJ d 3H1 SV S3A2f3S NOIlvOIlddV SIN! oN saA S31ON N01103dSNI 1VNI3 AlNO 3Sfl 2:10103dSNI 2:103 30Vd SIHL S31ON NOI103dSNI St/0 HJ(lO l