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HomeMy WebLinkAboutBLDG-23-001420 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l‘i\ CITY YARMOUTH I MA DATE September 16,202 PERMIT# BLDG-23-001420 JOBSITE ADDRESS 665 WILLOW ST OWNER'S NAME NEWTON ROBERT L A G OWNER ADDRESS WEISS MARSHA E 405 FRONT ST LINCOLN RI 02865 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 _ 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 mee:s the requirements of MGL Ch.142. YES El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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. S GNATURE 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 plL tubing 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 Timothy McElroy LICENSE# 15993 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION El# - PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Cape Cod Master Plumbers.Inc. ADDRESS_ 73 Cranberry Highway, CITY Saqamore STATE MA ZIP 02561 TEL FAX 1 CELL EMAIL S310N M31A3H NVId #1IV fld $ 33d ❑ ❑ 11M3d 3H1 SV S3AH3S NOIlYOIlddv SIHl oN saA S310N N01103dSNI 1VNId AINO 3Sf1 210103dSNI H0d 3OVd SIH1 S310N N01103dSNI SVO HOfOH