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HomeMy WebLinkAboutBLDG-22-003657 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T - CITY YARMOUTH MA DATE December 30,202'PERMIT# BLDG-22-003657 `t' JOBSITE ADDRESS 97 SOUTH SHORE DR UNIT 216 OWNER'S NAME SHORE ROAD ACQUISITION LLC G OWNER ADDRESS C/O NEWPORT HOTEL GROUP 28 JACOME WAY MIDDLETOWN RI 02842 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL J❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:D PLANS SUBMITTED:YES D 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:ATTIC SYSTEM 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 Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Cameron Natale LICENSE# MA SIGNATURE MP❑MGF Q JP❑ JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: ADDRESS, 200 Audreys Lane. CITY Marstons Mills STATE MA j ZIP 02648 TEL FAX 5085241272 CELL L743537354 EMAIL S31ON M3IAal Ndld #.R"JHJd $ =333 ❑ ❑ JIW2i3d 3H1 Sd S3A2l3S NOIld3llddv SIHI ON S9A S310N N01103dSNI lYNI3 lklNO 3Sl 210103dSNI 2IOd 3OVd SIHl S31ON N01103dSNI S,9 HJf10b