HomeMy WebLinkAboutBLDG-22-003155 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'"I' CITY YARMOUTH MA DATE 'December 02,2021 PERMIT# BLDG-22-003155
JOBSITE ADDRESS 53 HIGHBANK RD OWNERS NAME TOSTI AUGUSTINO
G OWNER ADDRESS TOSTI LILLIAN R PO BOX 274 SOUTH YARMOUTH MA 02664-0274 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑
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CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑
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
FRYOLATOR -
FURNACE
GENERATOR - ,
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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 LICENSE# SIGNATURE
MP 0 MGF 0 JP 0 JGF 0 LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: ADDRESS.
CITY STATE ZIP TEL
FAX CELL EMAIL
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