HomeMy WebLinkAboutBLDG-22-001855 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r, CITY YARMOUTH MA DATE October 02,2021 PERMIT# BLDG-22-001855
JOBSITE ADDRESS 12 MOHEGAN LN OWNER'S NAME DIAMOND DISTRICT RLTY LLC
G OWNER ADDRESS CIO DEVENDORF BRIAN 11 GOOSENECK LN SWAMPSCOTT MA 01907 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL
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CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
FIXTURES FLOORS—+ ' BSM 1 2 _ 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
BOOSTER -
CONVERSION BURNER _
COOK STOVE 1
DIRECT VENT HEATER
-
DRYER
FIREPLACE 1 _
FRYOLATOR _
FURNACE
GENERATOR
GRILLE 1
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:Grill installed outside
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 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 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# 33651 SIGNATURE
MP❑ MGF ❑ JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0#
COMPANY NAME: Thonus North PHAV ADDRESS. 12 Moheoan Lane,
CITY YarmouthPort STATE MA ZIP 02675 TEL 7745215698
FAX CELL EMAIL
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