HomeMy WebLinkAboutBLDG-21-004196 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
C BLDG-21-004196
CITY YARMOUTH MA DATE January 27,2021 PERMIT#
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JOBSITE ADDRESS 193 WHITES PATH OWNER'S NAME MID CAPE RACQUET CLUB INC
G OWNER ADDRESS C/O MAJEWSKI ASSOC INC 13200 OAKMONT DR FORT MYERS FL 33907-8030 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
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE 4
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurarce 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❑ 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
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 Albert Cassano LICENSE# 9015 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑ # PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: Fe Cod Mechanical Systems,Inc. ADDRESS. 8 Fruean Way,
CITY South Yarmouth STATE MA ZIP 02664 TEL 5083947501
FAX CELL 5087769536 EMAIL
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