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HomeMy WebLinkAboutBLDG-17-004053 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Frir[I6 CITY YARMOUTH MA DATE February 10, 2C PERMIT# BLDG-17-004053 JOBSITE ADDRESS 17 COPPER BROOK RD OWNER'S NAME ROBERTS STEVEN W G OWNER ADDRESS ROBERTS HEATHER L 17 COPPERBROOK RD SOUTH YARMOUTH MA TEL 02664-4332 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 1 GENERATOR GRILLE INFRARED HEATER i 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 Leonard Thonus LICENSE# MA 15520 SIGNATURE MP© MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Thonus North Plumbing, Heating&A ADDRESS 35 cottonwood Road, CITY Harwich STATE MA ZIP 02645 TEL 5084301150 FAX CELL 5082378764 EMAIL S31ON M3IA3b NVld #IIW2j3d $ :33J ❑ ❑IIW2I3d 31-11 SV SIAH3S NOI!V3I1ddV SIHl oN saA S31ON NO1123dSNI 1`dNld AlNIO 3Sf1 2101O3dSNI 2:JOd 3DVd SIH1 S31ON NOLLO3dSNI SVO HOfO2i