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HomeMy WebLinkAboutBLDG-22-001345 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -1-L ' CITY YARMOUTH MA DATE September 08,202 PERMIT# BLDG 22-001345 JOBSITE ADDRESS 22 HIDDEN ACRES AVE OWNERS NAME CHRISTENSEN CHERI L G OWNER ADDRESS 22 HIDDEN ACRES AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 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 _ 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 1 OTHER DESCRIPTION:Gas Meter Relocation INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY 0 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 Daniel Lyne LICENSE# 4608 SIGNATURE MP❑ MGF © JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: Bosotn Gas DBA Nationalqrid ADDRESS. 40 Sylvan Rd, CITY Waltham STATE MA ZIP 02451 TEL FAX CELL EMAIL S31ON M31Aal NVId #1114213d $ 33H El 11Wii3d 3H1 SV S3A2J3S NOI1VOIlddV SIH1 ON seA S310N N01103dSNI 1VNId AINO 3Sl 210103dSNI 2103 3OVd SIHI S310N NOI103dSNI SVO HO11021