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HomeMy WebLinkAboutBLDG-22-005859 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '7 CITY 'YARMOUTH I MA DATE 'April13,2022 I PERMIT# BLDG-22-005859 t R JOBSITE ADDRESS 36 CLINTON DR OWNER'S NAME DEAN JON B G OWNER ADDRESS DEAN MELANIE S 36 CLINTON DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:ID REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑ FIXTURES FLOORS BSM 1 _ 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 _ 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 I 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 LICENSE# SIGNATURE MP❑MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX I CELL[ EMAIL S310N M3IA321 NYld #LIW2:13d $ :333 ❑ ❑ 11Mlaci 3H1 SY STQ:13S NOI1b01ldd`d SIHI oN saA S31ON NOI103dSNI 1VNId AlNO 3Sf1 d0103dSNI el0J 3OVd SIHI S310N NO103dSNI SVO HDflO