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HomeMy WebLinkAboutBLDG-22-000271 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK (: CITY YARMOUTH MA DATE July 16,2021 PERMIT# BLDG 22-000271 fi JOBSITE ADDRESS 42 WILLIAMS RD OWNER'S NAME STOLTZ JULIE ANN TR G OWNER ADDRESS ROBERTS ROSE RLTY TRUST 2 HAVERSTOCK RD FRANKLIN MA 02038 TEL_ TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO El 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 1 - 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:Oil to gas conversion. Test required. 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 LICENSE# SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N M3IA321 NVId #1IW213d $:33H ❑ ❑ 111/1213d 3H1 SV S3A213S NOIlVOIlddV SIH1 oN saA S310N N01133dSNI 1VNIH AINO 3Sfl 210103dSNI 210d 30Vd SIH1 S310N N01133dSNI SVO H0l021