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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 s 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 r Gbh yr FAX 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 •Ac, .-.'mfl",:2(10/ "s1-\ ' CKC Z(DS-( .tr(_ov—