Loading...
HomeMy WebLinkAboutBLDG-22-007043 /p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (June 06,2022 I PERMIT# BLDG-22-007043 JOBSITE ADDRESS 939 WEST YARMOUTH RD OWNERS NAME THERRIEN PAMELAJ G OWNER ADDRESS PO BOX 188 YARMOUTH PORT MA 02675-0188 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL III PRINT • CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT.0 PLANS SUBMITTED:YES❑ NO❑ 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 © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El 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 Cameron Natale LICENSE# 4600 SIGNATURE MP❑MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME ADDRESS. 200 Audreys Lane, CITY Marstsons Mills STATE MA ZIP 02648 1 TEL FAX CELL 7743537354 EMAIL S310N NVld #iIW2i3d $ :33d ❑ ❑ 1111213d 3E11 SV S3A213S NOI1V3llddd SIHJ oN saA S310N NO1103dSNI 1VNI3 AINO 3Sl 210103dSNI 2103 39Vd SIHI S310N NOI103dSNI S11J H9flO