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HomeMy WebLinkAboutBLDG-17-005035 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 31, 2017 PERMIT# BLDG-17-005035 JOBSITE ADDRESS 59 STRATFORD LN OWNER'S NAME NIGOGHOSIAN JACK G OWNER ADDRESS NIGOGHOSIAN AZNIV 5 LAWNDALE AVE WALTHAM MA 02154-6830 TEL TY PE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW ElRENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD 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 © 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 NAMEIWalter Nye I LICENSE#I32083 I SIGNATURE MP❑ MGFD JP© JGF❑ LPGI❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC❑#I COMPANY NAME: IWALTER R NYE I ADDRESSI1 CANARY LN, CITY WEST YARMOUTH STATE IMA I ZIPI026733718 I TEL I FAX I CELL I I EMAIL' Z^N k )"2— 1 S31ON M31A3H NV-Id #JJV dd $ :333 ❑ ❑IIV I d 3H1 SV S3nb3S NOIlV011ddV SIHI ON SO), S31ON NO11O3dSNI 1VNId JC1NO 3Sfl 2JO133dSNI 2iOd 30Vd SIHI S31ON NO11O3dSNI SVO HOfOH