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HomeMy WebLinkAboutBLDG-19-000140 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK :s CITY YARMOUTH MA DATE July 09,2018 PERMIT# BLDG-19-000140 4 JOBSITE ADDRESS 29 LAKEWOOD RD OWNER'S NAME CARDONE THOMAS A G OWNER ADDRESS [CARDONE DENISE M 86 WHITTAM AVENUE SPRINGFIELD MA 01118 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW El 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 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: i 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 El 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#I4546 I SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: KEVIN C SAUNDERS ADDRESSI67 HELMSMAN DR, CITY YARMOUTH PORT STATE MA ZIPI026752467 I TEL I I FAX CELL EMAIL' I S31ON MAIA32:1 NV1d #IIW213d $ r33d JIW2i3d 3H1 SV S3ne3S NOIlVOIIddV SIHl oN §aA SALON NOIlO3dSNI 1VNIH .LINO 3Sfl 2iO103dSNI 210d 39Vd SIHI S310N NOILO3dSNI SVO HJflOH