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HomeMy WebLinkAboutBLDG-22-002970 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1n •'kb,,,,,_ BLDG-22-002970 d CITY YARMOUTH MA DATE November 22,2021 PERMIT# JOBSITE ADDRESS 9 HIDDEN ACRES AVE OWNER'S NAME MITSIS ANDREW G OWNER ADDRESS MITSIS DEBORAH 9 HIDDEN ACRES AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 - GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM!SPACE HEATER ROOF TOP UNIT TEST 1 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY❑ 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 William Holmes I LICENSE# 4592 SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPG( 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: I I ADDRESS. 19 Hunters Trail, CITY (Sandwich I STATE MA ZIP 025632701 TEL I FAX I CELL I EMAIL ( I /`. 9310N MIA NVId #III I3d $:333 ❑ 0 1101213d 3H1 SV S3A213S NOI1VOIlddV SIH1 oN saA S310N NOI103dSNI IVNIJ AlN0 3Sfl IO103dSNI 210d 3OVd SII-11 S310N NOI103dSNI SVO HJl02i