HomeMy WebLinkAboutBLDG-18-002684 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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x_;416 CITY Yarmouth 1 MA DATE 10/3112017 IPERMIT# /%1461-18.C42260/1
JOBSITE ADDRESS 47 Mockingbird Lane OWNERS NAME Hautanen,Mary Ellen
GOWNER ADDRESS 47 Mockingbird Lane,W.Yarmouth,MA 02673 TE 508-394-1476 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL ❑ RESIDENTIAL '❑
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:[._] PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER P I
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER ..
FIREPLACE
FRYOLATOR y
FURNACE '
GENERATOR t
GRILLE INFRARED HEATER
LABORATORY COCKS — f
MAKEUP AIR UNIT I
OVEN I _
POOL HEATERF . :'_ 1m
ROOM/SPACE HEATER i
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER ;,
WATER HEATER
OTHER --
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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 [D OTHER TYPE INDEMNITY [,] 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.
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 compliar�ye witfj.ell.Pe vent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. W !(J(
PLUMBER-GASFITTER NAME William B.Holmes LICENSE#j 394r 2 , SIGNATURE
MP❑ MGF❑ JP[,] JGF D LPG'Q CORPORATION❑#I ]PARTNERSHIP❑#j LLC❑#
COMPANY NAME:I Wiliam B.Holmes j ADDRESS19 Hunters Trail
CITY Sandwich STATE MA ]ZIP102563 TEL 1774-269-9797
FAX I —1 CELL - EMAIL bholmes27@yahoo.com
ROUGH GAS INSPECTION NOTES THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
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L.e`' �-5 FEE: S PERMIT [ (//TL
,/.�/-y ?LAN REVIEW NOTES
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