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HomeMy WebLinkAboutBLDG-22-000992 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY YARMOUTH MA DATE August 20,2021 PERMIT# BLDG-22-000992 li= y`" JOBSITE ADDRESS 31 KENNEDY LN OWNER'S NAME KRUMINS VALDIS I CO-TRS G OWNER ADDRESS CIO NIKULA ROBERT R 31 KENNEDY LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 111 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 1 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 NAME LICENSE# SIGNATURE MP❑ MGF ❑ JP 0 JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX 7 CELL EMAIL S310N M31A321 NVid #111Na3d $:33d ❑ ❑ 111183d 3H1 SY SS/WMS NOI1VOIlddV SIH1 oN saA S310N NO1133dSNI 1VNId AINO 3Sl 210133dSNI i10.d 30Vd SIHJ. S310N N01103dSNI SVJ H'Jl021