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HomeMy WebLinkAboutBLDG-23-000670 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE August 09,2022 PERMIT# BLDG-23-000670 JOBSITE ADDRESS 67 TAFT RD OWNER'S NAME HAWKES GEOFFREY G TR G OWNER ADDRESS GEOFFREY G HAWKES LIVING TRUST 67 TAFT RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: m RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 1 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 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 submined 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 LICENSE# PL16972-M SIGNATURE MP©MGF 0 JP 0 JGF❑ LPG'❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IVargov Mechanical I ADDRESS. 12 Grassv Pond Dr. CITY 'Dennis I STATE MA ZIP 026382514 TEL FAX CELL 7742127267 EMAIL I S310N M3IA32i NVld #II012j3d $ :33A ❑ ❑ 1I N 3d 3H1 Sb S3A213S N011t/011dd%,SIN' oN saA S310N NO1103dSNI 1VNI3 AlNO 3S71 H0103dSNI HOd 3DVd SIH1 S31ON NO103dSNI SVO HOf102i