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HomeMy WebLinkAboutBLDG-22-003330 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK " `M CITY YARMOUTH MA DATE December 11,202'PERMIT# BLDG-22-003330 ff fy JOBSITE ADDRESS 1117 NOTTINGHAM DR I OWNER'S NAME LEES MING G OWNER ADDRESS LEE JENNIE 117 NOTTINGHAM DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 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 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 State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Michael Grillo LICENSE E 33651 SIGNATURE MP❑MGF 0 JP❑ JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME, Thonus North PHAC ADDRESS, 12 Mohegan, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5084301150 FAX CELL EMAIL S310N MIA Ndld #JIW213d $ :33d El El 1I1NH d 3H1 SV S3AH3S NOLLV011dd`d SIH1 oN saA S310N NOI103dSNI 1VNld AlN0 3sn :10103dSNI 2JO 130Vd SIHl S310N NOI103dSNl SVO HJl02J