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HomeMy WebLinkAboutBLDG-22-001199 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE September 01,202 PERMIT# BLDG-22-001199 JOBSITE AD DRESS 38 DANBURY ST OWNER'S NAME Kevin Driscoll G OWNER ADDRESS 38 DANBURY ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS—w 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 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 0 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 David Simmons LICENSE# 116259 I SIGNATURE MP© MGF 0 JP 0 JGF 0 LPG' ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: I ADDRESS. 4 Jeannes Way, CITY IForestdale I STATE MA ZIP 102644 I TEL FAX 1 !CELL 1 1 EMAIL devlinsimmonsllc(a pmail.com S310N M31A32i NVId #111AN3d $ 33d ❑ ❑ 111,11?J3d 3H1 SV S3AN3S NOI1VOIlddV SIH1 oN saA S31ON N01103dSNI 1VNId AlNO 3Sf1210103dSNI 2JOd 30Vd SIHI S310N N01103dSNI SVO HOf1021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERM(T TO PERFORM GAS FITTING WORK CITY YeerwN0(A-LN MA DATE - ( ZI PERMIT# N JOBSITE ADDRESS 3cs Oa `ou vtc --e.k OWNERS NAME , zV i'l V ri CO C( ... OWNER ADDRESS c3CS Oct-LA OL1 S _-- - TEL$-G'-63N6t(OS" FAX ui c J U c • xPOROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[�}� LU y�� cY Y NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ cemT APPLIANCES-1 FLOORS-4 BSIvi 1 2 3 1 5 6 7 8 9 10 11 12 13 1 R 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 SPACE HEATER ROOF TOP UNIT TEST 1 . . . . ._ -- .. UNIT HEATER UNVENTED ROOM HEATER • WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Bj 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 ❑ • 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 ertinent provision of the `` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. b PLUMBER-GASFITTER NAME LICENSE#1661 SIGNATURE MP'v4GF❑ (�JP ❑ JGF❑ LPG' ❑ CORPORATION❑# 4 PARTNERSHIP❑# LLC[4' 3?75- COMPANY NAME�1 �>~J�C(�\16\ C(Wl S 1— — ADDRESS 3 & "�S u CITY ( ciilT -c(-e STATE ZIP 219 44 TEL -110 0 FAX CELL EMAIL Dev It 1nJ1VLlwiOvIS L^L CelA,Lccit 'co on 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