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HomeMy WebLinkAboutBLDG-22-002515 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1c CITY YARMOUTH MA DATE November 02,202'PERMIT# BLDG-22-002515 �' JOBSITE ADDRESS 121 SILVER LEAF LN OWNER'S NAME AGELOPOULOS JAMES L LIFE ESTATE G OWNER ADDRESS AGELOPOULOS DEAN J 1058 ALBEMARLE RD NORWOOD MA 02062 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT❑ PLANS SUBMITTED:YES❑ 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 FIREPLACE FRYOLATOR FURNACE 1 1 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 El BOND ❑ OWNERS 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 0 MGF 0 JP❑ JGF❑ LPG! ❑ CORPORATION El# PARTNERSHIP ❑# LLC❑# COMPANY NAME ADDRESS. CITY I I STATE ZIP TEL I FAX CELL EMAIL I S310N M31Aal Ndld #1IV d $ :33d ❑ ❑ JJ1A183d 3H1 SV S3A2i3S NOLLVOIlddV SIHI oN saA S310N NO1103dSNI 1VNld A1NO 3Sf1 d0103dSNI JOd 30b'd SIHl SiLON NO11O3dSNI Sb0 HOl0H