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HomeMy WebLinkAboutBLDG-22-004962 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '_.3c L z'' CITY YARMOUTH MA DATE March 08.2022 PERMIT# BLDG-22-004962 ",„ JOBSITE ADDRESS 41 MERRYMOUNT RD OWNER'S NAME SHAHEEN ROBERT S G OWNER ADDRESS SHAHEEN LISA M 5 MARGARET RD STONEHAM MA 02180 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL EI PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 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 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 LICENSE# PL16972-M SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Vargov Mechanical LLC ADDRESS. 2 Grassy Pond Dr, CITY Dennis STATE MA ZIP 026382514 TEL FAX CELL 7742127267 EMAIL S310N M3IA321 NV1d #11M3d $:33d CI ID 11M3d 3H1 SV S3AH3S NOI1V31lddV SIHI ON seA S310N NO1133dSNI 1VNId AINO 3Sl 2l0133dSNI 210d 3OVd SIHl S3 LON NO1133dSNI SVO HOl0N