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HomeMy WebLinkAboutBLDG-18-002399 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 18, 20' PERMIT# BLDG-18-002399 JOBSITE ADDRESS 26 COOLIDGE RD OWNER'S NAME ALMEIDA ANTHONY J G OWNER ADDRESS 26 COOLIDGE RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El PRINT CLEARLY NEW El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YESE NOD 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 0 OTHER OF INDEMNITY El 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 David Koss LICENSE# 10377 SIGNATURE MP© MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: David J Koss ADDRESS 36 WASHINGTON AVE. CITY W YARMOUTH STATE MA ZIP 026732434 TEL FAX CELL EMAIL N S31ON M3IA31 NV1d #1IW213d $ :33d ❑ ❑1IV fld 3Hl SV S3AH S NOIlv011ddv SIHl oN sa1 S31ON NOIL03dSNI 1VNId AINO 3Sf1 210103dSNI 2iOd 3OVd SIH1 S31ON NOI103dSNI SVO HJfO21