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HomeMy WebLinkAboutBLDG-23-000288 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w' CITY 'YARMOUTH I MA DATE 'July19,2022 IPERMIT# BLDG-23-000288 "` JOBSITE ADDRESS 19 MOORING LN I OWNERS NAME HEISLER THOMAS J G OWNER ADDRESS THOMPSON-HEISLER TERESE 9 MOORING LANE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO 0 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 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY BOND 0 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 Cameron Natale LICENSE# 4600 SIGNATURE MP❑MGF El JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. 20 Audreys Lane, CITY Marstons Mills STATE MA ZIP 02648 TEL 5087753083 FAX CELL EMAIL S310N M3IA3H NVld #±IW213d $ :39d 1:1 El 1I1,11H3d 3HI SV S3A213S NOIlV011ddV SIHl oN sOA S31ON NO1103dSNI 1VNId AlNO 3Sfl O103dSNI 8Od 2OVd SIHI S310N NOI103dSNI SVO Ronal I