HomeMy WebLinkAboutBLDG-22-006378 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
< CITY YARMOUTH MA DATE May 04,2022 PERMIT# BLDG-22-006378
JOBSITE ADDRESS 24 HARBOR RD OWNER'S NAME DAVENPORT DEWITT P TRS
G OWNER ADDRESS SOUTH YARMOUTH NOMINEE TRUST 20 NORTH MAIN ST SOUTH YARMOUTH MA TEL
02664
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO El
FIXTURES FLOORS--+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
- — r
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:Replacement of gas pipe
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 El 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❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# _ PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: ADDRESS.
CITY STATE ZIP TEL
FAX CELL EMAIL
S310N MSIA321 NVId
#111/ 3d $:33d
❑ ❑ 1111d3d 3H1 SV S AH3S N0IlV0IlddV SIH1
oN se),
S310N N011O3dSNI 1VNId AlN0 3Sfl a0103dSNI 2MOd 3OVd SIHI S310N N01103dSNI SVO HOl02J