HomeMy WebLinkAboutBLDG-23-001291 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
11 CITY YARMOUTH MA DATE September 12,202 PERMIT# BLDG-23-001291
JOBSITE ADDRESS 4 DEBS HILL RD UNIT 9A OWNER'S NAME HENNESSEY THERESA
G OWNER ADDRESS CIO SWAN FAMILY 14 MELBOURNE RD MILTON MA 02186 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El 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 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 El 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 Charlie Markarian LICENSE# 9197
SIGNATURE
MP El MGF ❑ JP El JGF❑ LPGI El CORPORATION❑# PARTNERSHIP ❑# Lc El#
COMPANY NAME: THE PIPE DOCTOR ADDRESS. PO Box 2227,
CITY Hyannis STATE MA ZIP 02601 TEL 5087756670
FAX CELL EMAIL
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