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HomeMy WebLinkAboutBLDG-23-001328 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `1_ o CITY YARMOUTH MA DATE September 12,202 PERMIT# BLDG 23 001328 % JOBSITE ADDRESS 41 JERUSHA LN OWNER'S NAME MCNEILL WAYNE E G OWNER ADDRESS MCNEILL DOREEN M 29 LANDERS ROAD STONEHAM MA 02180 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: m 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 1 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 1 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 El BOND El 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 Fernando Coelho LICENSE# 16897 SIGNATURE MP© MGF 0 JP❑ JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: All Cape HVAC and Plumbing Inc ADDRESS. 16 wildwood Path, CITY West Yarmouth STATE MA ZIP 02673 TEL 5083645425 FAX CELL EMAIL S310N M3IA321 NVId #iIIN213d $:333 ❑ ❑ 1111113d 3H1 SV S3A213S NOI1VOIlddV SIHI oN saA S310N N01103dSNl 1VNId AINO 3Sfl N0103dSNI 210d 30Vd SIH1 S310N NO1103dSNI SVO HJf1021