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HomeMy WebLinkAboutBLDG-22-002103 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r -\c' CITY YARMOUTH MA DATE October 13,2021 PERMIT# BLDG 22 002103 JOBSITE ADDRESS 18 DAYTON RD OWNER'S NAME POWERS KEITH R G OWNER ADDRESS POWERS MARIA A 18 DAYTON RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 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 0 BOND 0 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 Albert Cassano LICENSE# 9015 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Cape Cod Mechanical Systems,Inc. ADDRESS. 8 Fruean Way, CITY South Yarmouth STATE MA ZIP 02664 TEL 5087769536 FAX CELL 5083947501 EMAIL S31ON M3IARI N Id #±IWb3d $ 33� 111Na3d 3H1 SV S3/\213S N011vOIlddv SIHl ON saA S31ON NOI103dSNI IYNId AlNO 3Sf1 a)103dSNI 2IOd 3OVd SIH1 S310N NO1103dSNI SYJ HOf102i