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HomeMy WebLinkAboutBLDG-23-002764 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 17,202; PERMIT# BLDG-23-002764 JOBSITE ADDRESS 30 MOSS RD OWNER'S NAME Margy Simpson G OWNER ADDRESS MA 02493 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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. 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 Thomas Bulger LICENSE# 10099 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: THOMAS P BULGER ADDRESS. 10 PIPER ST, CITY QUINCY STATE MA ZIP 021696428 TEL FAX CELL EMAIL iustinna.longfellowdb.com fp0.60 MA L ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _5 -CITY: / I DATE: /1)//) ) PERMIT# -�,7 V.7 N�V 17 2)2SITE ',DRESS: 31) /1IL1S3' OWNER'S NAME: /IdjAx:‘i!Ly l ' J./4/ 11ii OWNER •,RESS: C // t)S J TEL: 0/" d //�IN�LPART MF_NT ' aj' TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:[a' RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ` BOOSTER CONVERSION BURNER COOK STOVE Qy DIRECT VENT HEATER �.l DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE VI INFRARED HEATER ''� LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER `I ROOF TOP UNIT t TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [2110 0 If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY ❑ 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 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 ail Pertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: i)Unig.S f eI1% f- LICENSE# , Ud1 q4✓ SIGNATURE" G�x COMPANY NAME: �.ESY1 i''Y/JYII.. ,S I fl t.ii/d ADDRESS: 1/11 /!1zz 12 5 l CITY: ,(mD STATE://t I ZIP: O ) 1O FAX: TEL: '7'71/'a5S—l70, CELL b/ 7-1d k EMAIL i'zsmbnJ rr 2 0' arng// 5 MASTER 0 JOURNEYMAN 0 LP INSTALLER❑ CORPORATION ariii / PARTNERSHIP 0# LLC❑#