HomeMy WebLinkAboutBLDG-22-02483 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
try- CITY YARMOUTH MA DATE 'October 31,2021 I PERMIT# BLDG-22-002483
JOBSITE ADDRESS 115 HEATHER LN I OWNER'S NAME 'GOODWIN BARBARA J
G OWNER ADDRESS CIO BRETT GOODWIN 36 GETTY CIR FAIRFIELD CT 06824 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES El NO Q'
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 I 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 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 Matthew Scioletti LICENSE# 27041 SIGNATURE
MP 0 MGF 0 JP❑ JGF❑ LPG' ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑A
COMPANY NAME: ADDRESS. 58 Townhouse Ter,
CITY Hyannbis STATE MA ZIP 260100000 TEL
FAX CELL EMAIL
S310N M3IAal NV1d
#JIWH3d $ :33d
El 0 IIW213d 3Ii1 SV S3M3S NOIlVOIlddd SR-U
ON seA
S31ON NO1103dSNI 1VNId A1N0 3Sf1 i0103dSNI HOd 3OVd SIH1 S310N NO1103dSNI SVO Rona]