HomeMy WebLinkAboutbldp-20-002856 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�! YARMOUTH 11/12/19
=1 a CITY MA DATE PERMIT# P,ILI1P-40-40a$io
JOBSITE ADDRESS 97 QUARTERMASTER ROW OWNER'S NAME JAMES VICCARO
GOWNER ADDRESS SAME TEL 717-712-6024 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL 0
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CLEARLY NEW: ❑ RENOVATION: El REPLACEMENT: 0 PLANS SUBMITTED: YES❑ NO❑�
APPLIANCES 1 FLOORS-) BM 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
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ID NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑■ OTHER TYPE 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.
CHECK ONE ONLY: OWNER El AGENT El
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ar true and accurate to est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn nce witr all P i nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME DOUG LANGTRY LICENSE# 11305 GA N RE
MP❑■ MGF El JP El JGF El LPG'El CORPORATION El# PARTNERSHIP❑# LLC❑■ # 3081
COMPANY NAME AQUA SERVICES PLUMBING &HEATING ADDRESS 1200 ROUTE 28
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-619-3367
FAX 508-619-3367 CELL EMAIL DOUG-AQUA@COMCAST.NET
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# / �'/ /
PLAN REVIEW NOTES ��� L' /71—