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HomeMy WebLinkAboutBLDG-22-006364 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V.�' CITY YARMOUTH MA DATE May 04,2022 PERMIT# BLDG-22-006364 I' JOBSITE ADDRESS 106 PHEASANT COVE CIR OWNER'S NAME PARENT THEODORE E G OWNER ADDRESS PARENT PEGGY H PO BOX 37 YARMOUTH PORT MA 02675 TELI TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 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 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❑MOP❑JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: ADDRESS. CITY STATE ZIP L J TEL FAX CELL EMAIL S310N M3IA321 NTH #IIW2j3d $:33J ❑ ❑ 11INa3d 3H1 SV S3A213S NOI1VOIlddd SIHL oN saA S310N NOI103dSNI 1VNId KINO 3Sfl JO103dSNI 210d 30Vd SIH1 S310N NOI103dSNI SVO HOf108