HomeMy WebLinkAboutBLDG-22-003168 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"�' - CITY YARMOUTH MA DATE 'December 03,2021I PERMIT# BLDG-22-003168
t JOBSITE ADDRESS 191 STATION AVE OWNERS NAME POPILLO JAMIE S
G OWNER ADDRESS 191 STATION AVE SOUTH YARMOUTH MA 02664 TEL'
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES El NO El
FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST 1
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❑ OTHER OF INDEMNITY❑ BOND ❑
OWNERS 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 I LICENSE# 'MA I SIGNATURE
MP❑MGF El JP 0 JGF❑ LPG' 0 CORPORATION El#I I PARTNERSHIP ❑# LLC❑#I
COMPANY NAME: I I ADDRESS. 1200 Audrevs Lane,
CITY IMarstons Mills I STATE MA ZIP 102648 TEL I
FAX 15085341272 I CELL 17743537354 1 EMAIL I 1
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