HomeMy WebLinkAboutBLDG-23-001354 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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1-1.14111 CITY [YARMOUTH J MA DATE September 14,202 PERMIT# BLDG 23 001354
JOBSITE ADDRESS 15 HAYWOOD AVE -1 OWNER'S NAME SMEDLEY KENT B
G OWNER ADDRESS SMEDLEY NEUCIMARI B 15 HAYWOOD AVE SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
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CLEARLY NEW: ❑ RENOVATION:❑ 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 -
DIRECT VENT HEATER
DRYER
FIREPLACE FRYOLATOR
FURNACE
GENERATOR 1
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❑
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 tre 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 plurnbing 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 Cameron Natale LICENSE# 4600 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: [ ADDRESS. 200 Audreys Lane,
CITY MArstons Mills STATE MA ZIP 02648 TEL 5087753083
FAX 1 CELL EMAIL
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