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HomeMy WebLinkAboutBLDG-21-003533 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 6 BLDG-21-003533 CITY YARMOUTH MA DATE December 23,202( PERMIT# `';" JOBSITE ADDRESS 64 MCNAMARA AVE OWNER'S NAME RIVEST CLAIRE E TR G OWNER ADDRESS C/0 CRAIG COLEMAN 3 KENS LANE SOUTH PARIS ME 04218 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ 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 GENERATOR , GRILLE , INFRARED HEATER , LABORATORY COCKS MAKEUP AIR UNIT OVEN , POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 , 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 0 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 eeland Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME (1A t S L I Su/al LICENSE# SIGNATURE MP❑ MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: I-1I h £1- C r i;N c), ADDRESS. CITY STATE ZIP TEL if-s-— 3 G 9S— FAX CELL EMAIL 8310N M3IA3N NVId # $ 33d ❑ ❑ 1111N3d3H1SVS3A213SN011tl01lddVSIHl Ste!' /Z/1,// >?a !S3 1 ON SOA S31ON NO1103dSNI 1VNId AlNO 3Sf1 NO103dSNI NOd 39Vd SIHl S310N NO1103dSNI SVO kOf10N