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HomeMy WebLinkAboutBldg-22-002013 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k: cY CITY YARMOUTH MA DATE October 08,2021 PERMIT# BLDG-22-002013 JOBSITE ADDRESS 37 PEREGRINE LN OWNER'S NAME MARK AND TRACY SIMONELLI TRUST G OWNER ADDRESS P 0 BOX 285 BROOKFIELD MA 01506 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 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 GENERATOR 1 , GRILLE , INFRARED HEATER . LABORATORY COCKS MAKEUP AIR UNIT , OVEN POOL HEATER ROOM I 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 El 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 Cameron Natale LICENSE# MA SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 200 Audreys Lane, CITY Marstons Mills STATE MA ZIP 02648 TEL J FAX 5085341272 CELL 7743537354 EMAIL S31ON M3IA32I NV-Id #1IIN213d $:93d ❑ 0 1I11213d 3H1 SV S3A213S NOI1VOlidd`d SIHl oN saA S310N NOI103dSNI 1VNI3 /LINO 3Sf1 80103dSNI 2JOd 39Vd SIHL S310N NOI103dSNI WO HJf102!