HomeMy WebLinkAboutBLDG-19-000543 •
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY YARMOUTH MA DATE July 26, 2018 PERMIT# BLDG-19-000543
JOBSITE ADDRESS 21 EBB RD OWNER'S NAME HICKEY PETER TRS
G OWNER ADDRESS HICKEY ANNE J 21 EBB RD YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW ❑ RENOVATION:❑ ' REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES FLOORS > BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
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BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE 1
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
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MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
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ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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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 ❑ NOD
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 Richard Olsen LICENSE# 2166 SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# 2166 PARTNERSHIP ❑# LLC❑#
COMPANY NAME: The Hokum Rock Corp. Inc ADDRESS PO BOX 2026,
CITY Dennis STATE MA ZIP 02638 TEL
FAX CELL i EMAIL
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
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