HomeMy WebLinkAboutBLDG-23-002987 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'irk-14 CITY 'YARMOUTH- I MA DATE (December 01,2021 PERMIT# BLDG-23-002987
JOBSITE ADDRESS 170 OLD MAIN ST I OWNER'S NAME 1KENNEDY ANN ELIZABETH EST OF
G OWNER ADDRESS C/O TD BANKNORTH NA TR 90 PEARSON BLVD AT:CHARTKOWSKI GARDNER MA TEL I
01440
TYPE OR I
OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0
PLANS SUBMITTED: YES ❑ NO
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 1 •
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
•
OTHER
OTHER DESCRIPTION:
•
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. 0
YES NO❑I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ 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.
PLUMBER-GASFITTER NAME (Justin Hogg I LICENSE# 132412
SIGNATURE
MP 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION GI#I I PARTNERSHIP ❑#I ILLC 0#1
COMPANY NAME: (Justin Hogg Plumbing&Heating Inc. I ADDRESS. 163 swift brook rd,
CITY (SOUTH YARMOUTH
I STATE IMA I ZIP 1026644041 I TEL 15082373694
FAX I I CELL I I EMAIL I