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HomeMy WebLinkAboutBLDG-19-004314 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 25, 20- PERMIT# BLDG-19-004314 ALV JOBSITE ADDRESS 11 HIALEAH AVE OWNER'S NAME FRAZEE JAMES R G OWNER ADDRESS FRAZEE JOYCE A 11 HIALEAH AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Li PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESD NOD 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 UNIT HEATER UNVENTED ROOM HEATER 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 ❑ NOD IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY ID 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 Kevin Saunders LICENSE# 4546 SIGNATURE MP❑ MGFQ JP❑ JGF❑ LPGID CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Kevin C Saunders ADDRESS 67 HELMSMAN DR, CITY YARMOUTH PORT STATE MA ZIP 026752467 TEL FAX CELL EMAIL S310N M3In32i NV1d #±Ivo:Gd $ :33d ❑ ❑1IWH3d dHl SV SAS NOI±VOl1ddd SIHl oN saA S31ON NOILO3dSNI 1VNId KINO 3Sf1 2IOLO3dSNI 2IOd 3DVd SIHI S31ON NOIIO3dSNI SVO HOfO2i