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HomeMy WebLinkAboutBLDG-22-002976 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 22,202'PERMIT# BLDG-22-002976 LL_� JOBSITE ADDRESS 29 WINCHESTER AVE OWNER'S NAME MALONE ANNE C(LIFE EST) G OWNER ADDRESS C/O MALONE MICHAEL 30 WINCHESTER AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES El NO El FIXTURES FLOORS-c 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 El 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 wit be in compliance with as Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME James Carabitses LICENSE E 11156 SIGNATURE MP El MGF❑JP 0 JGF El LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME A.RS Boston ADDRESS. 300 Manley St. CITY West Bridgewater STATE MA l ZIP 023790001 TEL 5085889025 FAX CELL EMAIL S31ON M3IA3�i NVld #lJVd d $ :33d ❑ ❑ 1IV d 3H1 SV S3A213S NOIlv31lddv SIH1 oN saA S31ON NO1103dSNI lYNId /ONO 3Sf1 10103dSNI 210d 39Vd SIHl S310N NO1103dSNI SVJ HOflO