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HomeMy WebLinkAboutBLDG-22-004529 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j CITY YARMOUTH MA DATE February 14,2022 PERMIT# BLDG-22-004529 JOBSITE ADDRESS 53 WILLIAMS RD OWNER'S NAME PLATT ROBERT LEONARD TRS G OWNER ADDRESS PLATT STEPHANIE ANN SCHUSTER TRS 302 ELLIOT RD CENTERVILLE MA 02632 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 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 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 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 ❑ 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 at 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 Kenneth Duarte LICENSE# MA SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. 37 collins ave. CITY Centerville STATE MA ZIP 02632 TEL FAX CELL EMAIL S310N M3IAR I NYld #1IIN2i3d $:33d ❑ ❑ 11111a3d 3H1.SV S3A83S N011v011dd`d SIHl oN saA S310N N01103dSNI 1VNId AlN0 3Sf1 e10103dSNI NOd 3OVd SIHI S310N NOI103dSNI SVD HOflO i