HomeMy WebLinkAboutBLDG-17-003373 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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e VS - CITY SOUTH YARMOUTH MA DATE 10/20/16 PERMIT#/./LDLT�I7—��1 I�9 7J
JOBSITE ADDRESS 42 LAKEFIELD ROAD OWNER'S NAME OMERZU _�
GOWNER ADDRESS 42 LAKEFIELD ROAD TELT08-280-4587 1FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL 7J RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES-1 FLOORS—, 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 I___
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__ _ 1
OTHER _
. 1- —
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES v NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY BOND j
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: OWN R J 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 the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian, with all ertine t ovisionsi of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - �A �-T/�
PLUMBER-GASFITTER NAME MARK MORAN LICENSE# 20786 SI NATURE C
MP❑ MGF .,j JP i.f JGF L LPG! CORPORATION❑#I 7 PARTNERSHIP #1 LLC L J#!
COMPANY NAME:! MORAN PLUMBING&HEATING _J ADDRESS 16 BRAMBLE BUSH DRIVE
CITY ZORESTDALE 1 STATE MA ZIP`02644 TELI508-648-2934
FAX CELL
CELL 508-648-2934 JEMAIL MORANPANDHEATING@GMAIL.COM
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