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Home My WebLink AboutBLDG-22-003378 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 ` 6e CITY YARMOUTH I MA DATE December 14,202' PERMIT# BLDG-22-003378 JOBSITE ADDRESS 71 NOTTINGHAM DR OWNER'S NAME NORLACH SHIRLEY A LIFE EST G OWNER ADDRESS 71 NOTTINGHAM DR YARMOUTH PORT MA 02675-0400 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: El RENOVATION:© REPLACEMENT:El 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEA-"ER WATER HEATER OTHER 1 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 CI 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 Gereral Laws. PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP❑ MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION El# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [ ADDRESS. CITY STATE ZIP TEL FAX ]CELL EMAIL S310N M31A3a NVId #JIWN3d $ 33d ❑ ❑ 111NTJ3d 3H1 SV S3A113S N011V3IlddV SIH1 .. l Zf l 2/2/ 4521—pia oN sa/, S310N N01103dSNl 1VNId A1N0 3S/1 H0103dSNI aOd 39Vd SIHl S31ON N01133dSNl S O HJh02!