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HomeMy WebLinkAboutBLDG-17-004161 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j=ll (r(6 CITY YARMOUTH MA DATE February 17, 2C PERMIT# BLDG-17-004161 �l JOBSITE ADDRESS 601 ROUTE 6A OWNER'S NAME YASHINA EKATERINA Y G OWNER ADDRESS CRUZ MARLON 601 ROUTE 6A YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL I'RINI' 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 : 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 ❑ 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 Alex Braga LICENSE# 15668 SIGNATURE MP© MGFE JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ALEX B BRAGA ADDRESS 2 MOUNTWOOD RD, CITY MARSTONS MLS STATE MA ZIP 026482111 TEL FAX CELL EMAIL S31ON M3IA H NV1d #JIW212d $ :33d ❑ ❑1IW213d 3H1 SV S3A2I3S NOIlV011ddV SIHl oN saA S31ON NOIlO3dSNI 1VNi3 J.INO 3Sfl HO1O3dSNI 210J 3OVd SIHl S3ION NOIIO3dSNI SVO HJflOH