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HomeMy WebLinkAboutBLDG-18-005369 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •f �� �°" 6 CITY YARMOUTH MA DATE March 28, 2018 PERMIT# BLDG 18 005369 JOBSITE ADDRESS 29 OLD CASTLE RD OWNER'S NAME MCDEVITT ELAINE M G OWNER ADDRESS 29 OLD CASTLE RD YARMOUTH PORT MA 02675 TEL TYPE 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 1 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 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 ❑ 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: seaside gas service inc ADDRESS 67 helmsman dr, CITY yarmouth port STATE MA ZIP 02675 TEL 5087712768 FAX CELL 5084000943 EMAIL t )1)(9 - - S3lON Mdln321 A ?! #1IW21d $ 3dd 11W213d 3H1 SV S3n211S NOI1VOl1ddV SIHI V oN saA S31ON NOILO2dSNI A-INO ASfl HO±OAdSNI 2=10d a0Vd SIHI SA1ON NOIlOadSNI SVO HOfOH