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HomeMy WebLinkAboutBLDG-22-005118 _r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a BLDG-22-005118 �' � CITY YARMOUTH MA DATE March 15,2022 PERMIT# _ Fi l i�- �1' ' JOBSITE ADDRESS 110 EVERGREEN ST OWNER'S NAME FALCONE RALPH A TRS G OWNER ADDRESS FALCONE ALICE C 110 EVERGREEN STREET SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ 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/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 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 Richard Whiteside LICENSE# 15850 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION LI# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [Nurphy's Services,Inc ADDRESS. 34 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660 FAX 1 CELL EMAIL S310N M3IM321 NVId #LIIN213d $ 33d ❑ ❑ 111%13d 3H1 SV S3h83S NOIlVOIlddV SIHI oN safe S31ON NO1133dSNI 1VNId AINO 3Sfl 210103dSNI 210d 3OVd SIHI S310N NO1133dSNI SVO HOfOH