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HomeMy WebLinkAboutBLDG-22-004666 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • CITY YARMOUTH 1 MA DATE February 23,2022 PERMIT# BLDG-22-004666 JOBSITE ADDRESS 33 ELLIS CIR -I OWNER'S NAME DUFVA ALFRED R G OWNER ADDRESS 33 ELLIS CIR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT ❑ PLANS SUBMITTED: YES ❑ NO ID 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 1 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 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY CI 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 Craig Bishop LICENSE# 15101 SIGNATURE MP❑ MGF El JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [High Efficiency LLC ADDRESS. 33 Ellis Circle, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5088253695 FAX CELL EMAIL S310N M3IA321 NVId #1IWN3d $:333 ❑ ❑ 1IIN d 3Hl SV S3A213S NOIlVOIIddV SIHI oN saA S310N NO1103dSNI 1VNId AINO 3Sfl 210103dSNI 210d 30Vd SIHI S310N NO1103dSNI SVO HOfON