Loading...
HomeMy WebLinkAboutBLDG-19-000514 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4ai CITY !Yarmouth I MA DATE7-24-18 I PERMIT#$cps/Q-00o&TI f JOBSITE ADDRESS'34 Midstream Drive OWNER'S NAME Bob and Ellen McDonoughG OWNER ADDRESS 34 Midstream Drive 1 TEL 508-694-6659 {FAX' f • TYPE OR OCCUPANCY TYPE COMMERCIAL',-) EDUCATIONAL '_j RESIDENTIAL',] PRINT CLEARLY NEW:') RENOVATION:L.I REPLACEMENT:;Li PLANS SUBMITTED: YES') NO'.,_1 APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 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 I I - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES (J NO ,._1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lid OTHER TYPE INDEMNITY ;J BOND Li 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 CHECK ONE ONLY: OWNER ;J AGENT 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 'th a ertinent provision of the Massachusetts State Pkambing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME David Simmons i LICENSE# 16259 SIGNATURE MP 5:.1 MGF! i JP' j JGF_J LPG!„ I CORPORATION)#I -PARTNERSHIP.,_)#, ( LLC Tf_j#,3975 — Devlin SimmonsCOMPANYNAME:.D i S __..mmons-_.__..__...__,__.______ s LLC �ADDRESS!4 Jeannes Way CITY ! Forestdale f STATE. MA IZIP,02644 ITEL1774521-3704 FAX I CELL508-64&2080 (EMAIL,DevlinSimmonsLLC@gmailcom - E CepEn 11 E Lt 1 �l� JUL 2 5 2018 !/( I 4-5 al tC riVIA di( 4.fr tgel ailif • • • I • j' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �r= ‘77:5:45 CITY Yarmouth MA DATE 7-2418 PERMIT# JOBSITE ADDRESS 34 Midstream Drive__ __-_ :OWNER'S NAME Bob andEllen McDonough GOWNER ADDRESS 34 Midstream Drive TEL 508-694-6659 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL _- EDUCATIONAL .., RESIDENTIAL -+- PRINT CLEARLY NEW: - RENOVATION: ..,. REPLACEMENT: J.: PLANS SUBMITTED: YES _ NO APPLIANCES 1 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 se FIREPLACE FRYOLATOR FURNACE GENERATOR t GRILLE INFRARED HEATER - LABORATORYCOCKS MAKEUP AIR UNIT - OVEN POOL HEATER ROOM!SPACE HEATER - ROOF TOP UNIT TEST I UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE 1 have aturrentliability insurance policy or its substantial equivaleiwhich meets the requirements of MGL.Ch.142 YES I NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -±..' OTHER TYPE INDEMNITY _ BOND I.._1 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. CHECK ONE ONLY: OWNER AGENT 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 'th a ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME David Simmons LICENSE# 16259 SIGNATURE MP _±i MGF __ JP JGF J LPG' , CORPORATION -# PARTNERSHIP__:# LLC ±# 3975 COMPANY NAME: Devlin Simmons LLC ;ADDRESS 4 Jeannes Way CITY Forestdale STATE MA !ZIP 02644 TEL 774-521-3704 FAX j CELL 508-648-2080 EMAIL DevlinSimmonsLLC©gmail.com_ _ �G E j'• k' - ka I 1 JUL 2 5 2018 ! ia � ,in r El ise A