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HomeMy WebLinkAboutBLDG-18-001212 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • r-, , Ga CITY YARMOUTH MA DATE September 01, . PERMIT# BLDG-18-001212 JOBSITE ADDRESS 155 BAYVIEW ST OWNER'S NAME KLANE LAWRENCE R TRS G OWNER ADDRESS KLANE PAULA P TRS PO BOX 278 HAMPTON NH 03843 TEL I Y PE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III 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 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 Sean Hanrahan LICENSE# 15822 SIGNATURE MP© MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: SEAN N HANRAHAN ADDRESS 34 N Precinct Rd, CITY Centerville STATE MA ZIP 026322643 TEL FAX CELL EMAIL S31ON M3IA32:1 NVld #JIW2:13d $ 333 El ❑1IW213d 3H1 SV S3n2J3S NOI1V011dd`d SIHl oN SG), S31ON NO1103dSNI ib'N13 AlNO 3Sf1 H0133dSNI 2:103 3OVd SIH1 S31ON NO11O3dSNI S` O HOfO2I