HomeMy WebLinkAboutBLDP-23-001802 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Ijr:iT CITY IYARMOUTH MA DATE (February 23,2023 PERMIT# BLDG-23-004708
JOBSITE ADDRESS 148 TODD RD OWNER'S NAME (DAVENPORT DEWITT TR
G OWNER ADDRESS DAVENPORT REALTY TRUST 20 NORTH MAIN ST SOUTH YARMOUTH MA 02664 TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL
PRINT ❑ RESIDENTIAL El
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO
111
FIXTURES FLOORS-I 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/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER OF 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.
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.
PLUMBER-GASFITTER NAME jeffery ricardo LICENSE# 13256 SIGNATURE
MP El MGF ❑ JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: (Patriot Plumbing Inc ADDRESS. 1538 Federal Furnace Rd,
CITY (Plymouth STATE MA ZIP 023604764 TEL
FAX CELL 15088464551 EMAIL 1