HomeMy WebLinkAboutBLDG-23-000811 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE August 16,2022 PERMIT# BLDG-23-000811
JOBSITE ADDRESS 18 SLEEPING DOG PATH OWNER'S NAME DAVIS GEORGE F
G OWNER ADDRESS DAVIS ELIZABETH N 33 NORTH MAIN ST SOUTH YARMOUTH MA 02664-3145 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
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
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR 1
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 El 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 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 David Houde LICENSE# 4333 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG! El CORPORATION El# 4333 PARTNERSHIP El# LLC ❑#
COMPANY NAME: McDonnell Mechanical Services ADDRESS. 79 School Street,
CITY West Dennis STATE MA ZIP 02670 TEL
FAX CELL EMAIL
S310N M3IA321 NVId
#llWa3d $ 33d
❑ ❑ 111N213d 3H1 SV S3A13S N011VOIlddV SIHl
ON seA
S310N NO1103dSNl 1VNId AINO 3Sfl N0103dSNI dOd 30Vd SIHl S310N NO1103dSNl SVO HJf10N