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HomeMy WebLinkAboutBLDG-22-002653 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -c CITY YARMOUTH MA DATE November 09,202'PERMIT BLDG-22-002653 l._ _F JOBSITE ADDRESS 28 CHARLES ST OWNERS NAME JENNEY AVA L LIFE EST G OWNER ADDRESS 28 CHARLES ST SOUTH YARMOUTH MA 02664-3104 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 1 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 0 NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY El BOND ❑ OWNERS 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 John McLaughlin LICENSE# 8704 SIGNATURE MP 0 MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑A LLC❑# COMPANY NAME: John Mclaughlin ADDRESS. 87 ROBBIE RD, CITY Braintree Ma 02184 STATE MA ZIP 02184 TEL FAX CELL 5089444948 EMAIL --- N S310N M3IARI NVld #iIWb3d $ 33d ❑ ❑ 111412:13d 3H1 SV S3/113S NOI1VOIlddV SIHl oN saA S310N NOI103dSNI 1VNld Jk1NO 3Sl 2J0103dSNI 210d 9OVd SIHJ S31ON N01103dSNI SV0 HJl0 1