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HomeMy WebLinkAboutBLDG-22-002349 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE !October 24,2021 I PERMIT# BLDG-22-002349 JOBSITE ADDRESS 158 PUTTING GREEN CIR J OWNERS NAME BALLOU SUSAN C TR G OWNER ADDRESS SUSAN C BALLOU REV TRUST 3 HILLCREST PARK RD OLD GREENWICH CT 06870 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO El FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 _ 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❑ 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 LICENSE E SIGNATURE MP❑MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N M31A32:1 NYld #iR J d $ :33� ❑ ❑ 111VEd 3H1 SV S3A1:13S NOI1VOIlddV SIHl oN sai S310N NO1103dSNI 1VN13 A7NO 3Sfl 2iO103dSNI HOd 3OVd SIHI S310N NOI103dSNI SVJ H0f10H