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HomeMy WebLinkAboutBLDG-22-003166 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE December 03,202'PERMIT# BLDG-22-003166 JOBSITE ADDRESS lib OLD HYANNIS RD OWNERS NAME SAUCIER HARRY G OWNER ADDRESS SAUCIER MARY D 16 OLD HYANNIS ROAD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO Q FIXTURES FLOORS—r 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 FRYOLATCR _ 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 1 _ 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 0 OTHER OF INDEMNITY BOND 0 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# SIGNATURE MP 0 MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N MIAA/131Aal NVld #lJWb3d $ :33d 0 El IIWb3d 3141 SV S3A213S NOI1v011ddv SIH1 oN saA S310N N01103dSNl lvNId AlNO 3Sfl H0103dSNI 2IOd 30Vd SIHI S31ON NO1103dSNI SVO HOflOH