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HomeMy WebLinkAboutBLDG-22-002155 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 15,2021 PERMIT# BLDG-22-002155 `i JOBSITE ADDRESS 17 WOODCREST LN OWNERS NAME KALFOPULOS ARTHUR F G OWNER ADDRESS HEIER IRENE 8 KALFOPULOS CATHERINE 551 WARWICK LN VENICE FL 34293 TEL I _ 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 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/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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 1 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 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑It COMPANY NAME 'SEASIDE GAS SERVICE INC I ADDRESS. 167 Helmsman Dr, CITY 'Yarmouth Port I STATE MA ZIP 02675 TEL 5087712768 FAX CELL 5084000943 EMAIL S310N M3IA3H NVld #11WN3d $ :33d ❑ ❑ II1A2fJd 3H1 SV S3A2f3S NOIlvallddd SIHI oN saA S310N N011D3dSNI 1VN13 AlNO 3Sfl NO1O3dSNI HOd 39Vd SIH1 S310N N01103dSNI SVD HJl02i