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HomeMy WebLinkAboutBLDG-23-001448 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •V�, CITY YARMOUTH MA DATE September 19,202 PERMIT# BLDG-23-001448 -t " JOBSITE ADDRESS 14 LAVENDER LN OWNER'S NAME GALKOWSKI MARK G OWNER ADDRESS GRANTHAM LYNDA G 14 LAVENDER LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ 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 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❑ 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 Kevin Saunders LICENSE# 308 SIGNATURE MP❑ MGF ❑ JP❑ JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768 FAX CELL 5084000943 EMAIL S310N M3IA3d NVId #11M3d $ 333 El El 11W2i3d 3H1 SV S3A:13S NOI1VOIlddV SI1-11 oN saA S310N NO1103dSNI 1VNld A1NO 3Sfl 210103dSNI),AN 3OVd SIH1 S310N NO1103dSNI SVO HOf1021