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HomeMy WebLinkAboutBLDG-22-003872 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w' S CITY YARMOUTH MA DATE January 11,2022 PERMIT# BLDG-22-003872 JOBSITE ADDRESS 11 WINCHESTER AVE OWNERS NAME ALEXANDER MARY C G OWNER ADDRESS 11 WINCHESTER AVENUE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 1 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 1 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 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 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 Matthew Coleman LICENSE# 34368 1 SIGNATURE MP❑MGF 0 JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP Oh 1LLC❑# COMPANY NAME: matt coleman plumbing and heating ADDRESS. 5 college st, CITY (west Yarmouth I STATE MA ZIP 02673 TEL 9788854343 FAX CELL 9788854343 EMAIL SSION M3IA32i NYld #.I1A2:13d $ :33d ❑ 0 1101a3d 3H1 SV S3A83S NOI1` OIlddV SIHI ON SeA S310N N01103dSNI 1VNId /LINO 3Sf1 80103dSNI 210d 39Vd SIH1 S310N NO1103dSNI SVO HOf10H1