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HomeMy WebLinkAboutBLDG-22-002855 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'V' = CITY YARMOUTH MA DATE November 17,202'PERMIT# BLDG-22-002855 JOBSITE ADDRESS 18 CANVASBACK LN I OWNER'S NAME COOKE GILMORE G G OWNER ADDRESS CRAWFORD LINDA 8 CANVASBACK LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ID PRINT CLEARLY NEW m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ 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 DIRECT VENT HEATER DRYER FIREPLACE 1 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 0 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 Imatthew Scioletti I LICENSE# Massachusetts SIGNATURE MP❑MGF 0 JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Scioletti Plumbing and Heating ADDRESS. 158 Townhouse Ter, CITY Ihyannis 'STATE MA ZIP 02601 TEL 17748100292 I FAX CELL 7748100292 EMAIL 1 S310N M31A32i NVld #.U1A1b3d $ :33d ❑ ❑ JIWH3d 3H1 SV S3A213S NOI1VOIlddV SIHI oN SBA S31ON N01133dSNI 1VNH AlNO 3Sfl 2i0103dSNI ZIOd 3OVd SIH1 S310N N01103dSNI SVJ HJfOH