HomeMy WebLinkAboutBLDG-19-001319 1
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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z';RI=z° CITY Yarmouth MA DATE LK2812018 (PERMIT# iX/26 77-OQ 136
• JOBSITE ADDRESS123 Lewis Bay,Blvd I OWNER'S NAME Brian Gallagher J
GOWNER ADDRESS Brian Gallagher TEL 508-330-2872 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONALRESIDENTIAL0
PRINT ❑
CLEARLY( NEW:❑ RENOVATION:LI REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑+
APPLIANCES Z FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 ;
BOOSTER 1 _ , ri i 1i 'i
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER I •i -
DRYER
FIREPLACE
FRYO(ATORIi ,
FURNACE • 1 •1 I . f ,i
GENERATOR F tl
GRILLE - - I - .
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN I _ ,
POOL HEATER _
ROOM I SPACE HEATERI i ,t 1 ti • y
ROOF TOP UNIT ,
TEST
UNIT HEATER , 7 `-
UNVENTEDROOM HEATER ,
WATER HEATER
OTHER
j - •
- , F S
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ 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.
I CHECK ONE ONLY: OWNER ❑ AGENT 0
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 prwvl Ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ^-w ''
PLUMBER-GASFITTER NAME Michael Maille LICENSE# 11355 I 11/4—'‘A—A--- --
SIGNATURE
MP +❑ MGF❑ P❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# 3609
COMPANY NAME: HomeServe USA Energy Services NE LLC ADDRESS 5 Constitution Way
CITY Woburn STATE MA ZIP 01801 TEL 781-359-2620
FAX CELL EMAIL rachel.whittick@homeserveusa.com 1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No I _ (lr
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �`rJ'�/,,,",
FEE: S PERMIT#
PLAN REVIEW NOTES 4 Q'
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