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HomeMy WebLinkAboutBLDG-22-003488 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK gCITY YARMOUTH MA DATE 'December 22,2021 PERMIT# BLDG-22-003488 JOBSITE ADDRESS 1104 HEATHERWOOD OWNER'S NAME ORMON GLORIANNA JOYCE TR G OWNER ADDRESS GDR REALTY TRUST 1104 HEATHERW00D YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 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!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 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 ❑ 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 at plumbing work and installations performed under the permit issued for this application will be in compliance with at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Cameron Natale LICENSE# ma 4600 SIGNATURE MP❑MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: ADDRESS. 200 Audrevs Lane, CITY Marstons Mills STATE MA ZIP 02648 TEL FAX 5085341272 CELL 7743537354 EMAIL S31ON M3IA32i NVld #iIW1J3d $ :33d 1IV 3d 31-11 SV S3Aa3S NOI.V011ddd SIH1 oN sa,A S310N N01103dSNI 1VNIA A1N0 3Sf H0103dSNI 210d 30Vd SIHJ S310N N01103dSN1 SVO HJl02f