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HomeMy WebLinkAboutBLDG-22-004108 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V' r CITY YARMOUTH MA DATE January25,2022 PERMIT# BLDG-22-004108 �„ JOBSITE ADDRESS 18 SKIPPER LN OWNERS NAME DAVIS ROY H G OWNER ADDRESS DAVIS KATHLEEN K 18 SKIPPER LN YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ 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 DIRECT VENT HEATER DRYER FIREPLACE 2 FRYOLATOR FURNACE GENERATOR GRILLE 1 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 0 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 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 dino depasquale LICENSE# MA SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# J PARTNERSHIP ❑# LLC❑# COMPANY NAME: victoria ADDRESS. 80 spencer knowles, CITY rowley STATE LMA ZIP 01969 TEL I6176406863 FAX CELL EMAIL S31ON M3IAal N ld #iIWZ13d $ :33d 0 0 111^1213d 3H1 SV S3AHRS NOLLY011ddV SIHl oN saA S310N N01103dSNI 1VNId AlNO 3Sfl 210103dSNI H03 30Vd SIHJ S310N NOI103dSNI SYJ HOfOb