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HomeMy WebLinkAboutBLDG-22-005045 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 11,2022 PERMIT# BLDG-22-005045 JOBSITE ADDRESS 126 WIMBLEDON DR OWNER'S NAME FOLEY RICHARD D G OWNER ADDRESS 7 FLAGG RD ACTON MA 01720-5611 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 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 ROOM/SPACE HEA DER 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 0 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 ❑ 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 Massaclusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER VAME sandy mclardy LICENSE# 5157 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 210 Pleasant bay rd., CITY harwich STATE MA ZIP 02645 TEL FAX 1 CELL EMAIL S31ON M3IA32:1 NVId #111V,I3d $:333 ❑ ❑ 111,1213d 3E11 SV S3A213S NOI1VOIlddV SIH1 oN s8A S310N NO1103dSNI 1VNId AINO 3Sfl 210103dSNI iiOd 30Vd SIHI S310N N01103dSNI SVO HOf1021