HomeMy WebLinkAboutBLDG-22-002147 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
w BLDG 22 002147
,� CITY YARMOUTH MA DATE _October 14,2021 PERMIT#
JOBSITE ADDRESS 10 JOHN HALLS CARTPATH VILL OWNER'S NAME REED ROBERT R JR
G OWNER ADDRESS 124 S MONTOWESE ST UNIT 5 BRANFORD CT 06405 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0
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 1
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
OTHER DESCRIPTION:ventless gas log fireplace
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑
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# MA SIGNATURE
MP 0 MGF 0 JP 0 JGF❑ LPG' 0 CORPORATION 0# __ _ PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: ADDRESS. 58 Townhouse Ter,
CITY hvannis STATE MA ZIP 026011400 TEL
FAX CELL EMAIL
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