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HomeMy WebLinkAboutBLDG-23-001191 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK voorq CITY YARMOUTH MA DATE September 03,202 PERMIT# BLDG-23-001191 JOBSITE ADDRESS 21 CLOVER RD OWNERS NAME LEARY RICHARD P G OWNER ADDRESS LEARY PATRICIA JOHNSON 21 CLOVER ROAD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ 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 1 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 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 matthew scioletti LICENSE# MA SIGNATURE MP 0 MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ADDRESS. 58 townhouse ter, CITY hyannis STATE MA ZIP 02601 TEL FAX CELL EMAIL S310N M3IA32i NVld #II Ja d $ :33d El El 1.11AN3c1 3H1 SV SaAH3S NOI1VOIldd`d SIHJ ON S8A S310N N01133dSNI 1VNId A1N0 3Sf1 b0103dSNI dOd 30Vd SIHl S310N N01103dSNl SVO Fiona'J