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HomeMy WebLinkAboutBLDG-23-001095 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Z-1". CITY YARMOUTH MA DATE August 30,2022 PERMIT# BLDG-23-001095 JOBSITE ADDRESS 14 ROUND DR OWNER'S NAME BLASKO STANLEY <T OWNER ADDRESS BLASKO BLANCHE 29 HALL AVE NASHUA NH 03064 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL 111 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/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 0 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# 14600 I MP El MGF El JP El JGF 0 LPG! 0 CORPORATION 0#I I PARTNERSHIP 0# SIGNATURE COMPANY NAME: ( I I 0#I I ADDRESS. 1200 Audreys Lane, CITY IMarstons Mills I STATE IMA I ZIP 102648 I TEL 15087753083 I FAX 1 1 CELL 1 1 EMAIL 1 S310N M3IA32i NVld #iIW?nd $ :333 111AN3d 3H1 SY S3AH3S NOI1v011ddy SIH1 ON seA S310N NO1103dSNI 1VNI3 AINO 3Sfl 2IO103dSNI 2f03 3OVd SIHI S310N NOI103dSNI SVO HOfO I