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HomeMy WebLinkAboutBLDG-20-006264 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '�ni 5ERMITBLDG-20-006264 CITY YARMOUTH MA DATE June 04,2020 # JOBSITE ADDRESS 22 FLINTLOCK WAY OWNER'S NAME GARNER STEPHEN H IV TR G OWNER ADDRESS THE STEPHEN HOLLA GARNER IV TRUST 54 CROSS RIDGE RD TUXEDO NY 10987 tEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Eil PRINT CLEARLY NEW: Q 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 _ FRYOLATOR FURNACE GENERATOR r GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 ROOM I 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 n 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. /_e� c�v � ,,���� / oo�© 1/3 1�lZo 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 Nick Theoharidis _ICENSE# PL34056-J SIGNATURE MP❑ MGF❑ JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# t LC ❑# COMPANY NAME: Theo Plumbing&Heating ADDRESS. 9 maureen rd, CITY centerville STATE MA 'IP 02632 TEL FAX IMMIlpELL �� MAIL air / ��