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HomeMy WebLinkAboutBLDG-22-003943 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11F CITY YARMOUTH MA DATE January 18,2022 PERMIT# BLDG-22-003943 JOBSITE ADDRESS 481 BUCK ISLAND RD UNIT 6CB OWNERS NAME BALDMAN CONSTANTINE A G OWNER ADDRESS 31 BOOTH RD DEDHAM MA 02026-5707 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID 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 1 _ 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 0 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 LICENSE# MA SIGNATURE MP❑MGF©' JP❑ JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS. 200 Audreys Lane, CITY Marstons Mills STATE MA ZIP 02648 TEL FAX 5085341272 CELL 7743537354 EMAIL S31ON M3IAal Ndld #1IIN d $ :333 ❑ El 111A183d 3H1 St/S3/1?:13S NOIlV011ddV SIHI oN seA S31ON NO1103dSNI 1VNE AlNO 3Sf1 b01O3dSNI 80d 39Vd SIH1 S3 LON N01153dSN1 SVO HD 102i