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HomeMy WebLinkAboutBLDG-23-001414 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lir; CITY YARMOUTH —I MA DATE September 16,202 PERMIT# BLDG-23-001414 JOBSITE ADDRESS 7 MEADOWBROOK RD OWNERS NAME DESMARAIS JEFFREY M G OWNER ADDRESS PAPADOPOULOS HELENA A 7 MEADOWBROOK RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES El NO El 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 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 El 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 Stephen Roberts LICENSE# 5104 SIGNATURE MP El MGF El JP❑ JGF El LPG! El CORPORATION 0# PARTNERSHIP ❑# LLC El# COMPANY NAME: ADDRESS. 17 lake dr, CITY Plymouth STATE MA ZIP 02360 TEL FAX CELL 5086480900 EMAIL S310N M31A32i NVld #1IWZI3d $ :33d III1H3d 3H1 SV S3A2:I3S NOI1V011ddV SIHI ON 58,E S310N N01103dSNI 1VNId AlN0 3Sfl 10103dSNI W)d 3OVd SIHi S310N N01103dSNI SVO HJl02f