HomeMy WebLinkAboutBLDG-22-003137 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,p e CITY YARMOUTH MA DATE December 01,2021 PERMIT# BLDG-22-003137
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JOBSITE ADDRESS 1297 ROUTE 28 OWNER'S NAME MCLAUGHLIN BRIAN J
G OWNER ADDRESS P 0 BOX 519 WEST BRIDGEWATER MA 02379 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
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/SPACE HEATER
ROOF TOP UNIT
TEST 1
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. YES ❑ NO❑
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 Damon Roche LICENSE# 12469 SIGNATURE
MP❑ MGF ❑ JP❑ JGF 0 LPG! 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME: DAMON G ROCHE ADDRESS. 26 middle street,
CITY south dartmouth STATE MA ZIP 02748 TEL
FAX CELL EMAIL rochecompound(7a comcast.net
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Air, DATE _\Z \\ c).\ PERMIT f 2 2 313 7
JOBSITE ADDRESS \‘�d\ \i-mG `III-.{ . Y OWNERS NAME% �y\ . 'N
G OWNER ADDRESS -1 Z.. �� \L
TEL
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PRINT
PE OR
OCCUPANCY TYPE COMMERC1 EDUCATIONAL ❑ RESIDENTIAL ❑
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑
PLANS SUBMITTED: YES❑ NO ❑
APPLIANCES T FLOORS. BSM 1 2 3 1 5 6 7
BOILER 9 to II 12 I;
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _____________
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT •
OVEN
POOL HEATER y
•ROOM/SPACE HEATER
ROOF TOP UNIT
TEST i ------
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liabifa insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YE^
h10 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POL161.to 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 ❑
`.r
.-, SIGNATURE OF OWNER OR AGENT
'I-: I hereby certify that all of the details and information I have submitted or entered regarding this
`, and that all plumbing work and installations performed under the permit issued for this application I' e e i aromplianctrue ane o wit accr II t rtinent provision the best of mylof the
edge
iLil
�` Massachusetts State Plumbing Code and Chapter•142 of the General Laws. qq
PLUMBER-GASFITTER NAME LICENSE# i �
'�4� SIGNATURE
I t
MPS MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑#.
COMPANY NAME Lw•cI-N® Ka-‘ ADDRESS �X, r\ flA
Y ,���\ ' '
CIT r.4B STATE �. ZIP ‘.1'1 L TEL CV U`1 `S`-6\—. d4\-j l
FAX 1 I
CELL EMAIL '1/4-'O t -,Cp.M ki
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