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BLDP&G-22-004287
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (February 01,2022 I PERMIT BLDP-22-004287 JOBSITE ADDRESS [9 HOLLY LN I OWNER'S NAME LIVINGSTONE DAVID C G OWNER ADDRESS LIVINGSTONE L C&BERGERON-WEST D&S 1467 CENTER ST LUDLOW MA 01056 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT© PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS-p 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 McBride LICENSE S 11620 SIGNATURE MP©MGF 0 JP 0 JGF 0 LPG( ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME Kevin McBride Plumbing and Heating,Inc. ADDRESS. 11 Cocheset Path, CITY West Yarmouth STATE MA ZIP 026732559 TEL 5087784556 FAX CELL 5083643724 EMAIL S310N M2IA32i NVld #JIIN213d $ :333 ❑ ❑ 1111213d 3H1 SV S3A 3S NOIIVOIlddv SIHJ oN seA S310N NO1103dSNI 1VNId AlNO 3Sfl 2i0103dSNI ZI03 39Vd SIHI S310N N01103dSNI SVD H9f1021