HomeMy WebLinkAboutBLDG-23-003183 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE December 08,202: PERMIT# BLDG-23-003183
JOBSITE ADDRESS r+..i i-.,, OWNER'S NAME PAMPOSH USA INC
G OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 1
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE 1 1
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER 1
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 2
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 El
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 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 William Mccarthy LICENSE# 9916 SIGNATURE
MP El MGF ❑ JP❑ JGF❑ LPG' El CORPORATION❑ # PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: WILLIAM E MCCARTHY ADDRESS. 1042 N Main St,
CITY Raynham STATE MA ZIP 027671744 TEL
FAX CELL EMAIL Ibwaterplumbinq a(�yahoo.com
_ /10 - 40L,
7•..� .sc '.` ,� a/ A SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
CITYit 41",0 LA& Arl(-�� MA L3 3 ) �
DATE (r 2� 217 PERMIT.r
BSli E ADDRESS
S €VAR S NAME P vSl4
U ITIDGIDE PAR6ey ADDRESS TEL FAX
PRINT OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL E RESIDENTIAL
CLEARLY NEW: ►:i RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO
Kii
APPLIANCES 1 FLOORS--F BSM 1 2 3 4 5 6 7 8 9 10 '11 12 13 14
BOILER
BOOSTER —�
CONVERSION BURNER,
COOK STOVE I —~
DIRECT VENT HEATER — I
DRYER
FIREPLACE i
FRYOLATOR
FURNACE -I r
GENERATOR
GRILLE
INFRARED HEATER j
LABORATORY COCKS i
MAKEUP AIR UNIT --I
OVEN I
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST . . l ,
UNIT HEATER '
UNVENTED ROOM HEATER
WATER HEATER _Z-___-
OTHER
k �1 t . -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of iVIGL.Ch.142 YES CEPIO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
•
LIABILITY INSURANCE POLIO' 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
Massarhus.el:ts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
‘1,1-• 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 coi ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME l..s, r)� 0d.C4A.A1/ LICENSE Rgt( SIGNATURE
MP' MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑#i PARTNERSHIP❑It LLC❑#i:
COMPANY NAME?Iz2sk,k4Lt PL �. ,,,-ri ADDRESS I UYZ fri- `kil 00 41" C I
CITY R A ill V44,\ STATE kl M ZIP c 2 ? G / TEL
FAX CELL ' - 5 `r C c. ;5 33 EMAIL B ch.4'Vo2 2tV W bad e `7 rlluc. 6.,