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HomeMy WebLinkAboutBLDG-22-005005 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1,N11,1) CITY YARMOUTH MA DATE March 10,2022 PERMIT# BLDG-22-005005 JOBSITE ADDRESS 75 MEADOWBROOK RD OWNER'S NAME MACFADGEN ERNEST G OWNER ADDRESS MACFADGEN D J&C 75 MEADOWBROOK RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY CI 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 mark Brindle LICENSE# MA SIGNATURE MP El MGF El JP El JGF❑ LPGI El CORPORATION❑# PARTNERSHIP ❑# LLC ❑# ] COMPANY NAME: ADDRESS. 102 Standish st, ] CITY pembroke STATE MA ZIP 02359 TEL 7812935316 ] FAX CELL 6176201758 EMAIL S310N MJIA321 NV1d #1I11213d $:33A ❑ ❑ .I11N3d 3Hl SY S3A213S NOIlVOIlddtl SIHL oN saA S31ON NO1133dSNI 1VNId AINO 3Sfl N0103dSNI 21Od 30Vd SIH1 S310N NO1133dSNI SVO HJfl02I