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HomeMy WebLinkAboutBLDG-22-001980 k � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY IYARMOUTH I MA DATE (October 06,2021 PERMIT# JOBSITE ADDRESS 11039A GREAT ISLAND RD I OWNER'S NAME 'BURDEN NANCY L TRBLDG 22-001980 G OWNER ADDRESS IC/0 JENKINS JOSEPH R TR 116 FLANDERS RD STE 1100 WESTBOROUGH MA 01581 TEL I TYPE OR OCCUPANCY TYPE I I PRINT COMMERCIAL❑ RESIDENTIAL 1/1 CLEARLY NEW: ❑ 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 FRYOLATOR FURNACE GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER • UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:Underground propane gas line. 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 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 'David Binder I LICENSE# 11278 I MP 0 MGF 0 JP 0 JGF❑ LPG( El CORPORATION 0# SIGNATURE I I PARTNERSHIP ❑#I ILLC 0#I I COMPANY NAME: 'Eastern Propane I ADDRESS. IPO Box 1207,3 New Venture Drive, CITY 'South Dennis I STATE 'MA I ZIP 102660 I TEL 15087602778 FAX 1 I CELL 1 I EMAIL I S310N M #11Wa3d $ 33d 11WiJ3d 3H1 SV S3M3S NOI1tl�IlddV SIHl oN SaA 8310N NO1103dSNI IVNI3 AINO 3Sfl HO103dSNI 2f03 30Vd SIHl SON N01103dSNl SVJ H`)f1021