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HomeMy WebLinkAboutBLDG-22-00160 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 15,2021 PERMIT# BLDG-22-002160 I-L. JOBSITE ADDRESS 16 UNCLE EPHRIAMS RD OWNER'S NAME STONE-LUNDY NANCY G OWNER ADDRESS 16 UNCLE EPHRIAMS RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ 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 r 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 BOND El 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 Eric Whiteley LICENSE# Massachusetts SIGNATURE MP El MGF ❑ JP 0 JGF❑ LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: IN'Vernon Whiteley ADDRESS. PO Box 1266, CITY West Chatham STATE MA ZIP 02669 TEL 5089451100 FAX CELL EMAIL S310N M3IA3N NVId # $:33H ❑ ❑ 11N1N3d 3Hl SV S3A213S NOLLVOIIddV SIHl oN saA S3LON NO1133dSNI 1VNId AINO 3Sfl N0103dSNI 2103 30Vd SIHl S310N N01103dSNI SVO H0f1021