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Home My WebLink AboutBLDG-22-001443 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .t_Io=!'k CITY YARMOUTH MA DATE September 13,202 PERMIT# BLDG-22-001443 cm JOBSITE ADDRESS 46 LOOKOUT RD OWNER'S NAME DOHERTY RAYMOND E G OWNER ADDRESS MCCLOY LYNETTE E PO BOX 136 YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS—j 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 2 FRYOLATOR FURNACE GENERATOR GRILLE 1 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 El 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 Thomas Bulger LICENSE# 10099 SIGNATURE MP El MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: THOMAS P BULGER ADDRESS. 10 PIPER ST, CITY QUINCY STATE MA ZIP 021696428 TEL FAX CELL EMAIL tombulger2 aRgmail.com S31ON MIA NVId #1IW213d $'33d El JV d 3HI SV S3AHSS NOI1VOIlddV SI1-11 oN sOA S310N NOI1O3dSNI IVNId A1NO 3Sl 210103dSNI NOd 30VdSIH1 S31ON NO1133dSNI SVO HOfl H MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK E-( Nt n() C L MA DATE E. '3 �vZ (PERMIT BSI E . DDRESS AL? \_ 1 -bG\, ('�( OWNER'S NAME ' r r''�• .. 3 20 • OWNE . A DRESS TEL FAX jarptitcc4PART MLNT y. ) ` 1-P-Al` JY TYPE COMMERCIAL ❑ EDUCATIONAL El RESI DENTIAL Oir CLEARLY NEW: RENOVATION: PLANS SUBMITTED: YES ❑ ❑ '� REPLACEMENT: ❑ .,UB��ITTED: 1 �S NO ❑ APPLIANCES FLOORS-4- 5SM 13 5 6 7 o BOILER BOOSTER CONVERSION BURNER ! COOK STOVE �- DIRECT VENT HEATER • I DRYER FIREPLACE FR'OLATOR FURNACE GENERATOR GRILLE I 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 - I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ® NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ( OTHER TYPE INDEMNITY ❑ BOND l OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage reguirer! by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives- this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT d` 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 4; and that all plumbing work and installations performed under the permit issued for this application will be in compli Pertinen rovi n of the iL 4. Massachusetts State Plumbing Code and Chapter '142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # 1 /0 0 9' ct SIGNA URE MP [ MGF ❑ JP ❑ JGF ❑ LPG' ❑ CORPORATION ❑ E PARTNERSHIP LLC [] COMPANY NAME 3v) cte" �L Y9 ADDRESS ` ?'% tp S4- CITY (1.1- •—) ry c STATE kYI N ZIP U.. (0 ` '� ^ 9 Z � �� TEL �O c.> 03 U FAX CELL EMAIL .C'1w, v‘ GC CoVA ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES