HomeMy WebLinkAboutBLDG-22-003699 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE January 04,2022 PERMIT# BLDG-22-003699
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JOBSITE ADDRESS 9 MOHEGAN LN OWNER'S NAME HANSON DOROTHEA W
G OWNER ADDRESS 9 MOHEGAN LN YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES El NO El
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
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 El 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 Michael Grillo LICENSE# MA SIGNATURE
MP❑ MGF 0 JP❑ JGF❑ LPG] ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: Thonus North PHAC ADDRESS. 12 Mohegan Lane,
CITY Yarmouth Port STATE MA ZIP 02675 TEL 7745215698
FAX CELL EMAIL
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