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HomeMy WebLinkAboutBLDG-22-001975 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 06,2021 PERMIT# BLDG-22-001975 kw, t( JOBSITE ADDRESS 17 PORTSMOUTH TERR OWNER'S NAME WILSON FRANCES E G OWNER ADDRESS 17 PORTSMOUTH TER YARMOUTH PORT MA 02675-2310 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: m 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 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 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY❑ BOND El 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 David Plum LICENSE# 15760 SIGNATURE MP© MGF El JP❑ JGF❑ LPG' 0 CORPORATION El# PARTNERSHIP El# LLC ❑# COMPANY NAME: Cape Associates Inc ADDRESS. P.O.Box 1858, CITY North Eastham STATE MA ZIP 02651 TEL 5082551770 FAX CELL 7743600930 EMAIL S310N M3IA321 NVId #11W213d $:33d ❑ ❑ lIV ]d 3141 SY S3A113S NOI1VOIlddtl SWl oN SG), S3lON N01103dSNl IVNId AINO 3Sfl 210103dSNI a0d 39Vd SIH1 S31ON NOIJO3dSNI SVJ H9fl02i