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HomeMy WebLinkAboutBLDG-20-004404 (2) I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ry BLDG-20-004404 k.Cille CITY YARMOUTHMA DATE Februa 11,2020 �ERMIT#Crr JOBSITE ADDRESS 17 CAPT YORK RD OWNER'S NAME ENGLAND NANCY A G OWNER ADDRESS 2012 EAST 131ST ST BIXBY OK 74008 11EL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NO FIXTURES FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 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 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 Stephen Ewing _ICENSE# 15281 SIGNATURE MP© MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑#I I PARTNERSHIP ❑# LLC ❑#� COMPANY NAME: STEPHEN D EWING ADDRESS. 1140 WHITE MOSS DR, CITY MARSTONS MLS STATE MA rIPI026481080 !TEL I FAX ,PELL EMAIL G+ G