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HomeMy WebLinkAboutBLDG-23-001334 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r ifI Y CITY YARMOUTH MA DATE September 13,202 PERMIT# BLDG-23-001334 JOBSITE ADDRESS 23 WINDSWEPT PATH OWNERS NAME MARSHALL-WRIGHTSMAN JANE G OWNER ADDRESS 83 WHEELER RD MARSTONS MILLS MA 02648 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO El FIXTURES FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14 BOILER 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❑ 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 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 Timothy McElroy LICENSE# 15993 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Cape Cod Master Plumbers,Inc. ADDRESS. 73 Cranberry Highway, CITY Saqamore STATE MA ZIP 02561 TEL 5083175525 FAX 1 CELL EMAIL S310N M31f\3d NVId #11M3d $ 33d El 1:1 111,483d 3H1 SV S3AH3S NOI1VOIlddV SIHI oN saA S310N NO1103dSNI IVNId AlNO 3Sfl NO103dSN1210d 3OVd SIH1 S310N NO1133dSNI SVO HJl0H