HomeMy WebLinkAboutBLDG-19-001144 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE August 27, 201l PERMIT# BLDG-19-001144
ti �I
JOBSITE ADDRESS 94 BROADWAY OWNER'S NAME PETRONE ADELE LIFE ESTATE
G OWNER ADDRESS 40 MAIN ST#407 STONEHAM MA 02180 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESE NO❑
FIXTURES FLOORS—I 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 1
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 El 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 Stephen Roberts LICENSE# 5104 SIGNATURE
MP❑ MGFE JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑
COMPANY NAME: STEPHEN W ROBERTS ADDRESS 17 LAKE DR,
CITY PLYMOUTH STATE MA ZIP 023605647 TEL
FAX CELL EMAIL
;(//e/x
)-(P
S31ON M3IA3?:I NV1d
#MAR: d $ :33d
111A1H3d 3H1 SV S3ANHS NOI1VOl1ddV SIHl
oN seA
S3lON NOII03dSNI 1YNII A-1NO 3Sf1 ?IO±O3dSNI ?JOB 3OVd SIHI S31ON NOI103dSNI SVO HOfOH