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HomeMy WebLinkAboutBLDG-22-006367 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK It\4," =6 CITY YARMOUTH MA DATE May 04,2022 PERMIT# BLDG 22-006367 ,ems).. rV JOBSITE ADDRESS 53 COLLINGWOOD DR OWNER'S NAME TIETGE ROGER P G OWNER ADDRESS TIETGE CHARYN A 53 COLLINGWOOD DRIVE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 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 1 , 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 El 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 Alexander Eaton LICENSE# 16715 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 5L0 long duck pond rd, J CITY Plymouth STATE MA ZIP 02360 TEL 7 FAX CELL EMAIL r- • S310N M31A321 NVId #11M3d $:33d ❑ ❑ LIV 3d 3H1 SV S3A213S NOI1VOIlddV SIH1 oN saA S310N N01103dSNI 1VNld AINO 3Sfl a0133dSNI'80d 3OVd SIH1 S31ON NO1133dSNI SVO HJl021