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HomeMy WebLinkAboutBLDG-22-003424 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY YARMOUTH MA DATE December 15,2021 PERMIT# BLDG-22-003424 JOBSITE ADDRESS 5 ROSETTA ST OWNERS NAME GIDDINGS DWIGHT G OWNER ADDRESS T FALINE/ADVENTURE RLTY TRUST 22 FLICKER LN MARSTONS MILLS MA TEL 02648-1346 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 1 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 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 0 OTHER OF INDEMNITY El 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 he in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE E SIGNATURE MP❑MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N M3lAal Ndld #iIWHAd $ :33d 0 0 JI1A2i3d 3H1 SV SAS NOLLVOIlddV SIHl oN saA SALON NOILO3dSNI 1VNId IYINO 3Sl 2101O3dSNI 21Od 3OVd SIHl S310N N01103dSNl St/0 HO lOb