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HomeMy WebLinkAboutBLDG-22-001736 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1ee4/ CITY YARMOUTH MA DATE September 27,202 PERMIT# BLDG-22-001736 rt JOBSITE ADDRESS 34 LUMBERJACK TRAIL OWNER'S NAME DESOUZA EDGAR C G OWNER ADDRESS 34 LUMBERJACK TRAIL WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ID PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:0 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 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:New Outside firepit.Underground gas piping 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 El 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 Fernando Coelho LICENSE# 34508 SIGNATURE MP 0 MGF 0 JP❑ JGF 0 LPG' ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: ADDRESS. 16 Wildwood Path, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL fernando252cta�pmail.com S31ON M3IA3H NVId #J JW2f3d $ 33d El El 11W?J3d 3H1 SV S3A?J3S NOI1VOIlddV SIH1 oN seA S31ON NO1133dSNI 1VNId AINO 3Sfl 2I0133dSNI 2JOd 3OVd SIHJ S31ON NO1133dSNI SVO HOl0H