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HomeMy WebLinkAboutBLDG-21-001901 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11 1 `'' CITY YARMOUTH MA DATE October 09,2020 PERMIT# BLDG 21 001901 1/4: JOBSITE ADDRESS 12 GILL AVE OWNER'S NAME LEVINE EMMONS S G OWNER ADDRESS 12 GILL LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:0 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 1 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 I 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY 0 BOND 0 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 Kevin Saunders LICENSE# 308 SIGNATURE MP 0 MGF 0 JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: FEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr, CITY Yarmouth Port STATE MA ZIP '02675 TEL 5087712768 FAX , CELL 5084000943 EMAIL S310N M31A32f NVId #1101213d $ 33d D ❑ 111183d 31-11 SV S3AN3S NOLLVOIIddV SIH± oN saA S310N NO1103dSNI 1VNId l lNO 3Sf1 NO103dSNI MOd 30Vd SIHl S31ON N01103dSNI SVO HJfION