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HomeMy WebLinkAboutBLDG-22-005851 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April13,2022 PERMIT# BLDG-22-005851 I" JOBSITE ADDRESS 4 MASSACHUSETTS AVE OWNERS NAME KELLY EDWARD J G OWNER ADDRESS ODEA-KELLY KATHLEEN A 143 CLIFF ROAD WELLESLEY MA 02481 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT 0 PLANS SUBMITTED:YES 0 NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE , INFRARED HEATER , LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 0 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 Ryan White LICENSE# 16068 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME ADDRESS. P.O.Box 425, CITY Harwich STATE MA J ZIP 02645 TEL FAX CELL EMAIL S31ON M31A311 Ndld #IIV i d $ :33J ❑ ❑ llINa3d 3E11 SV S3AH3S NOI1V011ddb SIHL oN saA S31ON N01103dSNI lYNId IINO 3Sl 210103dSNI 2JOd 39Vd SIH1 S310N NO1103dSNI SVO HOflO i