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HomeMy WebLinkAboutBLDG-22-003454 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e' rkik,. CITY YARMOUTH MA DATE December 20,2021 PERMIT# BLDG-22-003454 ti JOBSITE ADDRESS 6 FAIRWIND CIR OWNER'S NAME KANTZELIS ALIKI G OWNER ADDRESS 6 FAIRWIND CIR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL lIl PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 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 . GENERATOR GRILLE INFRARED HEATER , LABORATORY COCKS . MAKEUP AIR UNIT , OVEN POOL HEATER 1 ROOM I 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 LICENSE# SIGNATURE MP❑ MGF 0 JP 0 JGF❑ LPG! 0 CORPORATION❑# - PARTNERSHIP ❑# LLC 0# COMPANY NAME: ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL S310N M3IA32J NVId #1IW2i3d $:33d ❑ ❑ 1111213d 3E11 SV S3A213S NOI1VOIlddV SIHJ oN saA S310N NO1103dSNl lYNId KINO 3Sl 2J0103dSNI 21Od 3OVd SIHl S310N NOI103dSNI SVO HOf102J