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Home My WebLink AboutBLDG-22-002433 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (October 28,2021 I PERMIT# BLDG-22-002433 I JOBSITE ADDRESS 84 HOMERS DOCK RD OWNER'S NAME Alberto Maitino G OWNER ADDRESS 84 HOMERS DOCK RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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: 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 0 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 Nhan Nguyen LICENSE# 15210 SIGNATURE MP❑MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: NHAN H NGUYEN ADDRESS. 284 Bridge St, CITY Raynham STATE MA ZIP 027671975 TEL FAX CELL EMAIL hightek2010(1a.yahoo.com S310N M31Aal Nbld #lIW2j3d $ 333 -) 7 71 7 '10 El ❑ 111Al2i3d 31-11 Sd S3/1 13S NOLLVOIlddd SI1-11 ON SOA S3ION NO1133dSNI lYNId AlNO 3Sl 2101D3dSNI 1Od 30Vd SIN! S310N NO11O3dSNI St/0 H0f1021 • SD D,(_ ,.. FlllSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ;a=7 � * I_ V \ ' 1 . _ .r6 CITY ham, DATE Z U/2 ��yy 11 PERMIT# Z Z- 2 4 33 CT JOB AC DR SS 4 440-- t;e S oUC g-p OWNERS NAME AL 3v 4'c It1 °'f;n 4 g'. I IT.1 N G ptocivtai, S TEL ` -Sq U 46/.*„y Pit ` OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW: ►`.�) RENOVATION: ❑ REPLACEMENT: ❑ PLANSSUBMITTED: YES c '� ❑ NO❑ APPLIANCES 1 FLOORS-+ 6SIul 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER —� CONVERSION BURNER COOK STOVE I DIRECT VENT HEATER DRYER FIREPLACE - �— FRYOLATOR FURNACE - GENERATOR GRILLE n INFRARED HEATER LABORATORY COCKS �� MAKEUP AIR UNIT __ OVEN ; POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST , UNIT HEATER - Ut4VENTED ROOM HEATER WATER HEATER 1 OTHER t I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES x:`'NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _FP OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the l Massachusetts General Laws,and that my signature on this permit application waives-this requirement SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT El `. 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. L! PLUMBER-GASFITTER NAME kJ N I 4-3yC=ti LICENSE 4 tc 2( SIGNATURE MP MGF❑ JPtt❑ JGF❑ LPGI I] CORPORATION❑4 PARTNERSHIP[7]4LLC❑4 COMPANY NAME 1T 16 I-/ jr��iC' P 4 ADDRESS 2--g 6i,t 0 r CITY y K! w( STATE 1\4 ZIP O Z .?--" TEL ( - Z — 2 p FAX 1 ( � � � 9 / � CELL EMAIL /'L,.s CA-WC—24 i U • NOW- 1 1 rGr�i1 ct H 0 1 4, I C) C i _"' 1 11 or/ 1 - 0 f NI I 41 1 -V I ,.A t V I I -k.o : o ci:i W C) I -. H 1 W = F- z .. COLU. . .. _ _ . _ . . . � c4 w C ICO t Q Cra 71 F,,,1 I L r Ili 1 Z LU I-- u_ 1 I I i 0 1 i Ci W co] I jcri I0 V 1 I 1 1