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HomeMy WebLinkAboutBLDG-22-004612 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .................... CITY YARMOUTH MA DATE February 18,2022J PERMIT# BLDG-22-004612 JOBSITE ADDRESS 9 JERUSHA LN OWNER'S NAME GRANDE SAVERIO F G OWNER ADDRESS GRANDE JANET M 72 MARTIN ST WEST ROXBURY MA 02132 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ 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 ROOMI 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 ❑ NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El 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 William Holmes LICENSE# 4592 SIGNATURE MP❑MGF El JP❑ JGF❑ LPGI El CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: ADDRESS. 9 Hunters Trail, CITY Sandwich STATE MA ZIP 025632701 TEL 5084280449 FAX CELL EMAIL S31ON M31Aai NVld #.I01213d $:33d ❑ ❑ II1VEd 3H1 SV S3AH. S NOI1VOIlddV SIHl oN seA S310N NOI103dSNI lYNId AINO 3Sfl O103dSNI 2IOd 30Vd SIH1 S31ON NOI103dSNI SVO HOflO I