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HomeMy WebLinkAboutBLDG-22-001471 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w BLDG 22 001471 e CITY YARMOUTH MA DATE September 14,202 PERMIT# JOBSITE ADDRESS 37 JANICE RD OWNER'S NAME CHURCHILL PAIGE L G OWNER ADDRESS 37 JANICE RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ 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 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 1 OTHER DESCRIPTION:gas piping 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 ❑ 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 Brian Hibbard LICENSE# 11977 SIGNATURE MP El MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: [Cape Cod Plumbing and Heating Inc ADDRESS. PO Box 429, CITY South Dennis STATE MA ZIP 02660 TEL FAX CELL EMAIL S310N M3IA3a NVId #1IW213d $:333 ❑ ❑ 1I11 3d 3H1 SV S3Aa3S NOI1VOIlddV SIH1 oN saA S310N NO1103dSNI"kW WINO 3Sf1 a0103dSNI aOd 39Vd SIH1 S310N NO1103dSNI SVO HOl021