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HomeMy WebLinkAboutBLDG-16-04182 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l;�?s • n CITY YARMOUTH MA DATE January 21,20PERMIT# BLDG 16 004182 7. JOBSITE ADDRESS 86 PHYLLIS DR OWNER'S NAME ARSENAULT HAROLD T G OWNER ADDRESS ARSENAULT MURIEL N 86 PHYLLIS DR SOUTH YARMOUTH MA TEL 02664-1644 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW ❑ RENOVATION:© REPLACEMENT:El 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 1 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 © NOD 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 RICHARD WHITTLE LICENSE# 11648 SIGNATURE MP© MGFD JP❑ JGFD LPGID CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RICHARD H WHITTLE ADDRESS 67 OWL POND ROAD, CITY BREWSTER STATE MA ZIP 02631 TEL . FAX CELL EMAIL 'c 1Q' 6 f//Y/3,l7, o tv ,/$01 /440-7 S31ON M3IA3H NVld Cil T4// on/ #IIV d $ :Jd 4i0/44"V/1—'9 ©/fl ❑ IIV d dHl SV SAAH S NOI1V3I lddV SIH1 tf )10 qi /"MI oN seA S31ON NO1103dSNI 1VNid AINO 3Sfl 2iO133dSNI 2lOd 39Vd SIHI S31ON NOI1O3dSNI SVO HOf1O2I