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HomeMy WebLinkAboutBLDG-18-005054 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • qE 6 CITY YARMOUTH MA DATE March 15, 2018 PERMIT# BLDG 18 005054 1 JOBSITE ADDRESS 17 SHORE SIDE DR OWNER'S NAME PARMENTER HENRIETTA D LIFE EST G OWNER ADDRESS 17 SHORE SIDE DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW ❑ RENOVATION:0 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 1 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© MGF❑ 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 Cif ,1 // v/( :, 117 -'O S31ON M3IA H NV1d #IIW2Ad $ :33d 5 g �1 ❑IIV i3d 3H1 SY SA/WAS N011V011ddY SIHl oN saA S31ON NOI103dSNI 1VNIA )CNO 3Sfl 2:I0103dSNI 2i01 30dd SIHI S310N NOIL02dSNI SVO HJflO2i