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HomeMy WebLinkAboutBLDG-22-005085 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH —I MA DATE March 15,2022 PERMIT# BLDG-22-005085 JOBSITE ADDRESS 44 LOWER BROOK RD OWNER'S NAME ASH JANE L G OWNER ADDRESS 44 LOWER BROOK RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/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 Q NO❑ IF YOU CHECKED YES,F'LEASE 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 Fernando Coelho LICENSE# 34508 SIGNATURE MP❑ MGF ❑ JP I i JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 16 Wildwood Path, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX 1 CELL EMAIL fernando252c(c�dmail.com S310N MIA NVId #inAked $:333 ❑ ❑ 1111d3d 3H1 SY S3AU S NOIlV3Ilddv SIHI oN saA S310N N01103dSNI IVNId AINO 3Sl 210103dSNI 210d 30Vd SIHJ S310N N01103dSNI SVO HJl0H