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HomeMy WebLinkAboutBLDG-22-006809 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH I MA DATE May 24,2022 PERMIT# BLDG-22-006809 JOBSITE ADDRESS 139 MAINE AVE OWNER'S NAME PARGOLI MICHAEL R G OWNER ADDRESS 105 MELROSE ST ARLINGTON MA 02474 TEL _ TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 1 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 El 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-egarding 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 El MGF El JP El JGF❑ LPGI El CORPORATION❑# PARTNERSHIP ❑# LLC El# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX 1 CELL EMAIL S310N M31A321 NVId #1INH d $:333 ❑ ❑ 1IIN d 3H1 SY S3Ai13S NOI1tl3Ilddv SIH1 ON Se) S310N N01103dSNI 1VNId AINO 3Sfl a0103dSNI 2JOd 30Vd SIHI S310N N01103dSNI SVO HOfON