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HomeMy WebLinkAboutBLDG-22-003408 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 15,2021 PERMIT# BLDG-22-003408 JOBSITE ADDRESS L30 REFLECTION WAY OWNER'S NAME BARTHE SHAWN L G OWNER ADDRESS BARTHE JOAN E 2 DORNOCH RD RAYNHAM MA 02767 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL III PRINT CLEARLY NEW: m 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 1 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 7-- 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 `Stephen Roberts I LICENSE# 15104 I SIGNATURE MP❑MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: I I ADDRESS. 117 lake, CITY IDr I STATE MA ZIP 02360 TEL I FAX I I CELL EMAIL I S31ON M3IA321 NVld #IIN2i3d $ :333 ❑ ❑ 11111213d 3H1 Sb'S3AH3S NOIld011dd'd SI1-11 12(ZZ/i, -ylO oN S8A S310N N01133dSNI 1VNId AINO 3Sfl 210153dSNI 2i0d 39Vd SIHl S310N N01133dSNI SVJ HOl021