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HomeMy WebLinkAboutBLDG-23-000427 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH 1 MA DATE (July 27,2022 I PERMIT# BLDG-23-000427 JOBSITE ADDRESS 81 BLUE ROCK RD OWNERS NAME ROUNDS CAROLE A G OWNER ADDRESS 141 COCASSET ST FOXBOROUGH MA 02035 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 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 UNR 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 Justin Hogg LICENSE# 32412 SIGNATURE MP❑MGF El JP El JGF El LPG! 0 CORPORATION 0# PARTNERSHIP El A LLC❑# COMPANY NAME: 30645 ADDRESS. 63 swift brook rd, CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 5082373694 FAX CELL EMAIL S310N M3IA321 NV1d #11M3d $ :33d ❑ ❑ 11W213d 3H1 SV S3A83S NOIlv011ddb SIHI ON SaA S310N N01103dSNI 1VNId A1N0 3Sl 210103dSNI 2IOd 30Vd SIH1 S310N N01103dSNI St/0 H0f1021