Loading...
HomeMy WebLinkAboutBLDG-22-000800 BLD.2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August 11,2021 PERMIT# BLDG-22-000800 11 JOBSITE ADDRESS 497 ROUTE 28 -+ - OWNER'S NAME GRIFF HOLDING CORP G OWNER ADDRESS 497 MAIN ST WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY CI 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 El JP❑ JGF❑ LPG! El CORPORATION❑# PARTNERSHIP El# LLC ❑# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S31ON M3IA3d NVld #11W213d $:33d ❑ 0 111M3d3H1SVS3A2i3SNOLLV3IlddVSIHl \Z1 I -210 u'tfQV oN saA S31ON N01103dSNl TVNk AlNO 3Sfl H0103dSNI 210d 30Vd SIN' S31ON NO1103dSNI SVO HJl0N