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HomeMy WebLinkAboutBLDG-22-002931 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e CITY YARMOUTH MA DATE November 19,202' PERMIT# BLDG-22-002931 tf JOBSITE ADDRESS 56 SHORT WAY OWNER'S NAME JOHNSON RONALD R TRS G OWNER ADDRESS JOHNSON EVELYN D TRS 56 SHORT WAY WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ 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 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 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 Christopher Murphy LICENSE# 16548 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME Blue Bear Plumbing ADDRESS. 100 Corp Park Dr,Ste 1740, CITY Pembroke STATE MA ZIP 02359 TEL 7817064682 FAX CELL EMAIL S3lON M31A32!NVId #LI1A1b3d $:33d 111Va3d 3111 SV S3AinS NOI1VOIlddV SIHl oN saA S310N NO1103dSNI IVNId AINO 3Sfl H0103dSNI 210d 3OVd SIH1 S310N NO1103dSNI SVO HOflON