HomeMy WebLinkAboutBLDG-22-004411 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE February 08,2022 PERMIT# BLDG-22-004411
JOBSITE ADDRESS 7 HOLE IN ONE DR OWNER'S NAME OMALLEY JOHN J(LIFE EST)
G OWNER ADDRESS OMALLEY MARY JANE 7 HOLE IN ONE DR SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
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CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑
FIXTURES FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
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
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 Kevin Saunders LICENSE# 308 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# ]
COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr,
CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768 ]
FAX CELL 5084000943 EMAIL L
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