HomeMy WebLinkAboutBLDG-20-001309 a7171 re it Uj it-I
- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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__11=,y w Owe1 CITY Yarmouth Port MA DATE 09-04-19 PERMIT# - J�
JOBSITE ADDRESS 14 Forewind Rd OWNER'S NAME Thomas Maguire
GOWNER ADDRESS Same TEL 508-375-0921 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS-0 ' BSM ' 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER Q1
CONVERSION BURNER
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COOK STOVE
I1THEATER
I'r r If E 1 f
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GENERATOR
GRILLE (�
INFRARED HEATER 1
LABORATORY COCKS
MAKEUP AIR UNIT I1.1 II
OVEN O I _
POOL HEATER
ROOM I SPACE HEATER ( (( 1 I J
ROOF TOP UNIT
TEST
UNIT HEATER 1 11 I 11 Ii
UNVENTED ROOM HEATER
WATER HEATER
OTHER (l I 1 I I
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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 Q 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 ❑
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 ❑ AG T ❑
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 an. : u, cra;obi= •f� 'nowle e
and that all plumbing work and installations performed under the permit issued for this application will be in com•'- ce wit �• % io of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME Michael J. Maille LICENSE# 11355 SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC Li# 3609
COMPANY NAME:HomeServe USA Energy Services,NE,'ADDRESS 5 Constitution Way
CITY Woburn STATE MA ZIP 01801 TEL 781-359-2606
FAX CELL EMAIL Rachel.whittick@homeserveusa.com
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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THIS APPLICATION SERVES AS THE PERMIT El ❑ (iJS r�
FEE: $ PERMIT# 9 J]�' / gc ,
PLAN REVIEW NOTESC(7 l