HomeMy WebLinkAboutBLDG-22-004101 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
77-7.:4,4f
f CITY YARMOUTH MA DATE January 25,2022 PERMIT# BLDG-22-004101
JOBSITE ADDRESS 37 MIDSTREAM DR OWNER'S NAME GARDINER ROBERT C
G OWNER ADDRESS GARDINER THERESA D 111 HAVILAND ST QUINCY MA 02170 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO El
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
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
6
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 El
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 Gregory Selfe LICENSE# 26714 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP El# LLC El#
COMPANY NAME: GREGORY A SELFE ADDRESS. 41 SPRINGER LN.
CITY WEST YARMOUTH STATE MA ZIP 026734930 TEL
FAX CELL EMAIL
•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�..W 1_�„ CITY yft K MD c./t\ MA DATE /- a(I-a a
-'' PERMIT# 2`2 H kit
JOBSITE,ADDRESS ? 7 m ' o 51-1tl1r►\ De cVe /
OWNERS NAME_ C_'� 1Y,E
OWNER ADDRESS 3 7 P'I r Z SA-e r A m D e t ve TE(s.07) Ve Y 76 d FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL
❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT:
PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES 1 FLOORS. BSI1/1 1 ? 3 1 5 s 7
BOILER s 10 I'I 12 13 1,,
BOOSTER —_,
--
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER —`___H
FIREPLACE
i
FRYOLATOR
FURNACE I
______________I
GENERATOR
GRILLE �_)
INFRARED HEATER --
LABORATORY COCKS --, a I
MAKEUP AIR UNIT
OVEN -_
POOL HEATER ,} -i
ROOM!SPACE HEATER =_—
ROOF TOP UNIT
TEST _
UNIT HEATER
UNVENTED ROOM HEATER
•
WATER HEATER ________
I
OTHER
I
I
INSURANCE COVERAGE I
I have a current liabili insurance policy or its substantial equivalent vehich meets the requirements of MGL.Ch.142 YES El ND ❑
I IF YOU 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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑
'tl-• 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 co
`'' Massachusetts State Plumbing Code and Chapter'142 of the General Laws. ith all Pertinent provision of the
Li
PLUMBER-GASFITTER NAME fE60ty S,el FP LICENSE#
a67/Y SIGNATURE
MP ❑ MGF❑ JP ® JGF❑ LPGI ❑ CORPORATION ❑t PARTNERSHIP❑# LLC❑
COMPANY NAME K iG0 a 5...e I r( T hW✓1 S.n6ff Lyre L(( SPK to 6
ADDRESS F'e_ Lii 11 t
CITY_ (...-). yAKMoGY11
STATE )rn H ZIP 0.1-6 7 3 TEcS—c (3 Y
FAX Olt 5-02?). 1Q t�t3 ti EMAIL s et co
C- 3 2� v 1