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HomeMy WebLinkAboutBLDG-20-002444 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK S CITY YARMOUTH MA DATE October 29,2019 PERMIT# BLDG 20 002444 JOBSITE ADDRESS 20 TANGLEWOOD DR OWNER'S NAME FRANKEL JAMES A TR G OWNER ADDRESS C/O FRANKEL SUSAN 128 FRANCE RD BARRINGTON NH 03825 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL [3 PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO Q 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 1 GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST V UNIT HEATER I UNVENTED ROOtvI HEATER I WATER HEATER 1 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 Q NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ©1 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 here!v.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 Massie]r,setts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Whiteside LICENSE# 15850 SIGNATURE MP C j L1GF ❑ JP[] JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RICHARD J WHITESIDE ADDRESS. 29 MAPLE TER, CITY SOUTH DENNIS STATE MA ZIP 1026603651 1 TEL FAX 1 'CELL EMAIL S310N M3IA32I Ndld #11W?d3d $ :33d ❑ ❑ JI11H3d 3Hl SV S3A213S NOIIVOIlddV SIH1 oN SBA #-.S3ION N01103dSNI 1VNid KIND 3Sfl 2j0103dSNI 210d 30\fd SIHI S310N N01103dSNI SVO HDflOH