HomeMy WebLinkAboutBLDG-22-002988 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH
W,-,-,,---1---7
MA DATE November 23,202' PERMIT#
BLDG 22-002988
/:
JOBSITE ADDRESS 27 SATURN LN OWNER'S NAME Cory Weller
G OWNER ADDRESS 27 SATURN LN SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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
DIRECT VENT HEATER
DRYER
FIREPLACE 1 ,
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
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 El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 Douglas Langtry LICENSE# 11305 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: DOUGLAS P LANGTRY ADDRESS. 1268 ROUTE 28,
CITY S YARMOUTH STATE MA ZIP 026644459 TEL
FAX CELL EMAIL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'— N
YARMOUTH 11/19/2021
`. CITY MA DATE PERMIT#
i7
JOBSITE ADDRESS 27 SATURN LANE CORY WELLER
G OWNER'S NAME
OWNER ADDRESS SAME TEL 619-551-4141
FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑■ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑■
APPLIANCES- FLOORS-0 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 1
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
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El AGENT ❑
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to a est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P in t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME DOUG LANGTRY LICENSE# 11305 `j' �
NATURE
MP❑■ MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION ❑# PARTNERSHIP❑# LLC 0# 3081
COMPANY NAME AQUA SERVICES PLUMBING & HEATING ADDRESS 1200 ROUTE 28
CITY SOUTH YARMOUTH STATE MA ZIP 02664
TEL 508-619-3367
FAX 508-619-3367 CELL EMAIL DOUG-AQUA@COMCAST.NET