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HomeMy WebLinkAboutBLDG-22-004879 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r�'''` CITY YARMOUTH MA DATE March 03,2022 PERMIT# BLDG-22-004879 "'i JOBSITE ADDRESS 109 NOTTINGHAM DR OWNER'S NAME FARUP MERETE TR G OWNER ADDRESS MERETE FARUP REV LVG TRUST 109 NOTTINGHAM DRIVE YARMOUTH PORT MA TEL 02675 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 1 FRYOLATOR FURNACE 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 © 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 LICENSE# SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# ] COMPANY NAME: ADDRESS. ( ] CITY STATE ZIP TEL ] FAX CELL EMAIL 1 S310N M3IA321 NVld #1I01213d $ 33d ❑ ❑ 1I1,013d 3E41 SV S3A213S NOI1VOIlddV SIHI ON SG), S31ON N01103dSNI 1VNId AlNO 3Sfl N0103dSNI 2iOd 30Vd SIHI S31ON NO1103dSNI SVO HOfON