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HomeMy WebLinkAboutBLDG-22-005931 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 15,2022 PERMIT# BLDG-22-005931 �, JOBSITE ADDRESS 63 POMPANO RD _I OWNERS NAME DOOLEY JOSEPH M G OWNER ADDRESS DOOLEY ALDA&MARY DOOLEY-MCMAHON 16 IDA RD WORCESTER MA 01604 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑ 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/SPACE HEATER ROOF TOP UNIT • TEST _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I 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 I hereby certify that at 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 at 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 ben sadler LICENSE# 116133 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. 15 chipaway lane. CITY eastfreetown STATE MA ZIP 02717 TEL FAX CELL EMAIL S310N M3IA32J NVld #11112ind $:333 ❑ ❑ 1.J0183d 3H1 SV S3AbJ3S NOI1VOIlddV SIHI oN seA S310N NOI103dSNl 1VNld AlNO 3Sl 210103dSNI 210d 3DVd SIHI S310N NOI103dSNI SVD HOflO