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HomeMy WebLinkAboutBLDG-22-001815 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE September 29,202 PERMIT# BLDG-22-001815 { JOBSITE ADDRESS 722 WILLOW ST OWNER'S NAME SWENSON ALAN M G OWNER ADDRESS SWENSON LINDA M 10 MORNING GLORY CIR WESTFORD MA 01886 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL Q PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑ FIXTURES FLOORS 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 I 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 © NO 0 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 at 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 LICENSE# SIGNATURE MP❑MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION❑it PARTNERSHIP 0# LLC❑# COMPANY NAME ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N M3IA321 NVId #lJIN213d $ :33d ❑ ❑ 111,183d 3H1 SV S3/\ 13S NOI1VOIlddV SI1-11 oN saA S310N NOI103dSNI lb'NId AINO 3Sf H0103dSNI 2JOd 3OVd SIH1 S310N N01103dSNI SVO HOflO