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HomeMy WebLinkAboutBLDG-23-003665 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,L11 CITY YARMOUTH MA DATE January 05,2023 PERMIT# BLDG-23 003665 JOBSITE ADDRESS 12 ST ANDREWS WAY OWNER'S NAME JACKSON WILLIAM G OWNER ADDRESS C/0 FAUCHER FRANCIS 12 ST ANDREWS WAY SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT 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 BOOSTER , CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 1 FIREPLACE • FRYOLATOR FURNACE 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 0 BOND 0 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 (Georgi Vargov I LICENSE# IPL16972-M I SIGNATURE MP©MGF 0 JP 0 JGF❑ LPG] 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IVargov Mechanical LLC I ADDRESS. 128 Witchwood Rd, CITY 'South YarmouthISTATE MA ZIP 026642909 TEL I FAX CELL 7742127267 EMAIL I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ElE1 FEE: $ PERMIT# PLAN REVIEW NOTES