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HomeMy WebLinkAboutBLDG-22-003668 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY YARMOUTH MA DATE December 30,202'PERMIT# BLDG-22-003668 rlrA JOBSITE ADDRESS 73 SOUTH SHORE DR OWNER'S NAME BASS RIVER HOTEL LLC G OWNER ADDRESS 28 JACOME WAY MIDDLETOWN RI 02842 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL J❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:CI 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 I 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY O 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 4600 SIGNATURE MP❑MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ' I ADDRESS, 1200 Audreys Lane, CITY Marstons Mills ISTATE MA ZIP 02648 TEL I FAX 15085341272 I CELL 7743537354 EMAIL S310N M3IA32i NV1d #1I1AJH3d $ :333 ❑ ❑ 11Wa3d 3H1 SV S3AH3S NOIld3llddb SIHl oN saA S310N NO1133dSNI 1VNId AINO 3Sl d0153dSNI 210d 30VdSIHl S310N NOI133dSNI SVO HJl0H