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HomeMy WebLinkAboutBLDG-22-002110 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK yin -9` BLDG 22-002110 CITY YARMOUTH MA DATE October 13,2021 PERMIT# JOBSITE ADDRESS 41 MERRYMOUNT RD OWNER'S NAME SHAHEEN ROBERT S G OWNER ADDRESS SHAHEEN LISA M 5 MARGARET RD STONEHAM MA 02180 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© 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 _ OTHER 1 OTHER DESCRIPTION:Extended gas main from existing to new meter location. 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 Kevin Decoteau LICENSE# 16532-m SIGNATURE MP 0 MGF 0 JP❑ JGF❑ LPG' ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: ADDRESS. 38 Powhatan rd, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL S310N M31A3a NVId #1IWN3d $:33d 11VIInd 3H1 SV S3AN3S NOI1VOIlddV SIR! oN SBA S31ON NO1103dSNI 1VNId AINO 3Sfl 2:10103dSN1210d 3DVd SIHl S31ON NO1103dSNI SVO HOfON