HomeMy WebLinkAboutBLDG-22-006476 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
e "' ' / CITY IYARMOUTH MA DATE (May 10,2022 'PERMIT# BLDG-22-006476
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JOBSITE ADDRESS 171 SMITHS POINT RD OWNER'S NAME Patrick Coffey
G OWNER ADDRESS 02472 TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT PLANS SUBMITTED: YES El NO El
NEW: CIRENOVATION:❑ REPLACEMENT:CI
FIXTURES 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 '
FIREPLACE '
FRYOLATOR '
FURNACE '
GENERATOR
GRILLE '
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT '
OVEN '
POOL HEATER '
ROOM I SPACE HEATER '
ROOF TOP UNIT '
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER '
OTHER 1
OTHER DESCRIPTION:underground propane line
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY El 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.
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
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
I SIGNATURE
PLUMBER-GASFITTER NAME (David Roderick I LICENSE# 1967 I PARTNERSHIP 0#I (TLC 0#1 I
MP❑ MGF ❑ JP El JGF❑ LPG( 0 CORPORATION❑#I I
COMPANY NAME: IDAVID W RODERICK I ADDRESS. 183 CLEARWATER DR, I
CITY IHARWICH I STATE IMA I ZIP 1026452901 (TEL I I
FAX CELL EMAIL Iruss2ccaamail.com
, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ji= a7- CITY -y6YZ10G1, k MA DATE S-i0'-LZ PERMIT#
-.:.•. HAVOMNDREss 1/ crn I ttic POt lwA-D OWNER'S NAMEPAI2'X Co'
i .. _ .. r AI SC/v.—Q. TEL C,f�$a,f� L (o$�S FAX
,ILDII�RWL
T , YOR
PRINT UC ULIPANCY I Yrt COMMERCIAL❑ EDUCATIONAL ElRESIDENTIAL 2(
CLEARLY NEW:X RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO K
APPLIANCES- 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
FIREPLACE
FRYOLATOR - .
FURNACE
GENERATOR -
GRILLE -
INFRARED HEATER -
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN -
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER . .
izgeran (46 Grp
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES tic NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY N 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 beZ plianc with a rti ent pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f Q
PLUMBER-GASFITTER NAME-1 b VJ\ap Ei2.)& _c LICENSE# Ck\p--t SIGNATURE
MP❑ MGF❑ JP ❑ JGF p LPGI CORPORATION ❑# PARTNERSHIP ❑# LLC❑#
C C O\ ( J � ADDRESS -° `-�'�
COMPANY NAME �`\`` --_ C q r�.�n Q
CITyc �( C� \0\-A' r\ STATE�Q1 ZIP :v�� TEL-77(r l
FAX CELL So5-_1y`O--aO-\ EMAIL c. ,C_ t'' c-\�