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HomeMy WebLinkAboutBLDG-22-007390 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE 'June 23,2022 PERMIT# BLDG-22-007390 JOBSITE ADDRESS 110 LOOKOUT RD OWNER'S NAME IJARVIS MICHAEL G OWNER ADDRESS IJARVIS LINDA 110 CLUBHOUSE LN NORTHBRIDGE MA 01534 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL El PRINT RESIDENTIAL ID 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 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 'Georgi Vargov I LICENSE# 'PL16972-M I MP EaMGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# I SIGNATURE PARTNERSHIP ❑#I ILLC ❑#I COMPANY NAME: IVargov Mechanical LLC I ADDRESS. 12 Grassy Pond Dr, CITY (Dennis I STATE IMA I ZIP 026382514 TEL FAX 1 I CELL 17742127267 I EMAIL