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HomeMy WebLinkAboutBLDG-18-005643 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK sy6 CITY YARMOUTH MA DATE April 09, 2018 PERMIT# BLDG-18-005643 JOBSITE ADDRESS 80 MATTAKESE RD UNIT 5 OWNER'S NAME ANTONELLI JOSEPH F TRS G OWNER ADDRESS ANTONELLI PATRICIA TRS 1A SUMMIT RD MEDFORD MA 02155 TEL I'YPF.OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW ❑ 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 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 0 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 Kevin Saunders LICENSE# 4546 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Kevin C Saunders ADDRESS 67 HELMSMAN DR, CITY YARMOUTH PORT STATE MA ZIP 026752467 TEL FAX CELL EMAIL S31ON M3IA 1 Meld #±IWH3d $ :33d 1Ik 2d 3Hl SV S3A2i3S NOI1VOI1ddV SIHI oN seA S31ON NOLLOddSNI 1VNId )I-1NO dSfl eIO1O3dSNI HOd 3OVd SIHt S31ON NOLLO3dSNI SVO HOflOH