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HomeMy WebLinkAboutBLDG-22-003375 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ILxn '!� BLDG 22-003375 e CITY YARMOUTH MA DATE December 14,202' PERMIT# ti��" JOBSITE ADDRESS 482 WINSLOW GRAY RD OWNERS NAME OHARRA GLADYS ELIZABETH G OWNER ADDRESS 482 WINSLOW GRAY RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES El NO 0 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 l 11 12 13 14 BOILER BOOSTER _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ DRYER FIREPLACE FRYOLATOR FURNACE _ _ GENERATOR 1 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 El NO EJ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY El 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 Kevin Saunders LICENSE# 308 SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768 FAX CELL 5084000943 EMAIL S310N M3IA32:1 NVId #11WH3d $:33A ❑ 0 lIVILI3d 3E11 SV SAS NOIJ VOIlddV SIHl oN se,' S310N NO1103dSNI 1VNId A1NO 3S11210103dSNI HOd 30Vd SIH1 S310N NO1133dSNI SVD HJl0a