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HomeMy WebLinkAboutBLDG-23-000885 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH _1 MA DATE August 18,2022 PERMIT# BLDG-23-000885 • JOBSITE ADDRESS 21 ICE HOUSE RD OWNER'S NAME SWEDLUND THOMAS E G OWNER ADDRESS SWEDLUND CONNIE J 21 ICE HOUSE ROAD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATE R ROOF TOP UNIT TEST 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 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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Christopher Keith LICENSE# MA SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# _LLC ❑# COMPANY NAME: Keith Brothers Plumbing,Inc. ADDRESS. 19 Milford Street, CITY Plymouth STATE MA ZIP 02360 TEL 5083178577 FAX -7 CELL 5088632469 EMAIL S310N M31A321 NVld #1I1A213d $ 33d ❑ ❑ 111Nd3d 3H1 SV S3AH3S NOIiVOIlddV SIH1 oN saA S310N NOI133dSNI 1VNId AINO 3Sfl 2101O3dSNI 210d 3OVd SIHl S310N N01133dSNI SVO HOl0H