HomeMy WebLinkAboutBLDG-22-003714 . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
I = BLDG-22-003714
CITY YARMOUTH MA DATE January 04,2022 PERMIT#
a;
5.)
JOBSITE ADDRESS 30 MOSS RD OWNER'S NAME Curran Simpson
G OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER 1
OTHER DESCRIPTION:relocate gas main .
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
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 Thomas Bulger LICENSE# 10099 SIGNATURE
MP❑ MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME: THOMAS P BULGER ADDRESS. 10 PIPER ST,
CITY QUINCY STATE MA ZIP 021696428 TEL
FAX CELL EMAIL tombulger2(a,gmail.com
''ASSACHUSETTS UNIFORM APPLICATION FOR A PERMFT TO PERFORM GAS FITTING WORK
___, --7,04,4„,-.4 . , MEN& 11 z'-r'-
- ' _ MA DATE i; PERMIT# Z Z- 3 7 r L1
JAN 20 A2JO sr E ADDRESS _ N��
ii OWNERS NAME 1'Z' COr lox-,
Bui DING-AR-1 I E".ADDRESS
By - r r TEL
FAX
PRINK '.ANCY TYPE COMMERCIAL❑ EDUCATIONAL
CLEARLY ❑ RESIDENTIAL
NEW:❑ R.ENO'VATION: ❑ REPLACEMENT: A
PLANS SUBMITTED: YES❑ NO❑
BOP IANCES 1FLOORS-+ SEM 9 1 �
- 3 1 5 6 7 o 10
BOOSTER111111113 13 14
CONVERSION BURNER OTIO,
COOK STOVE
DIRECT VENT HEATER all
DRYER FIREPLACE
FRYOLATOR imil "1"... '''
FURNACE m
GENERATOR
GRILLE
imisMONI_______ ii.,
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN
POOL HEATER =-
ROOM/SPACE HEATER
ROOF TOP UNIT 1
TEST _
UNIT HEATER . Milliill
UNVENITED ROOM HEATER _
WATERHFJ'�l'ERmilli
OTHER • Imm_______,
iritomin iimi CCINSURANCE .
ERAGE
I have a current liabifa insurance policy or its substantial equivalent which Vmee s the requirements of NIGL.Oh.1142 YES
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I,!:; OTHER TYPE INDEMNITY ❑ BOND
OWNER'S INSURANCE WAIVER: El I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
f (Massachusetts General Laws,and that my signature on this permit application waives this requirement,
I.
SIGNATURE OF OWNER OR AGENT CHECKONE ONLY: OWNER ❑ AGENT ❑
".I- I hereby certify that all of the details and information I have submitted or entered regarding this application are ue d accurate to the best of my knowledge
`1 and that all plumbing work and installations performed under the permit issued for this application will be in c
Massachusetts State Plumbing Code and Chapter'142 of the General Laws. g
`} ce with all Pert' nt pr sion of the
PLUMBER-GASFITTER NAME �� ‘ti.1.4, �;\9 t.--"
LICENSE# 100 ci 7 SIGNATURE
MP MGF ❑ JP ❑ JGF❑ LPG( ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑
COMPANY NAME cl 1 G Cy ` L�j
ADDRESS_ (Cj p d. 54-
CITY )i2 s vL'c "1 STATE 'MA ZIP IP 17-
FAX �_ TEL ?v✓" t?S 3c)
CELL EMAIL �' 0 <." 01 a3,t