Loading...
HomeMy WebLinkAboutBLDG-23-000575 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vi"lilM",) s CITY YARMOUTH MA DATE August 04,2022 PERMIT# BLDG-23-000575 JOBSITE ADDRESS 259 OLD MAIN ST OWNER'S NAME DAVIS CONSTANCE H G OWNER ADDRESS 259 OLD MAIN ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: Ei RENOVATION:D 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 1 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 0 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 LICENSE# SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. CITY I STATE ZIP TEL FAX I —I CELL EMAIL I S310N M3IA3N NVId #.IIN2l3d $.33d ❑ ❑ 1II lH d 3H1 SY S3A213S NOIlVOIlddV SIHl ON SaA S310N N01103dSNI 1VNId AINO 3Sfl H0103dSNI HOd 30Vd SIH1 S310N N01103dSNI SVO HOf1021