HomeMy WebLinkAboutBLDG-17-003870 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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,. CITY YARMOUTH MA DATE January 30, 20' PERMIT# BLDG-17-003870
JOBSITE ADDRESS 32 IROQUOIS BLVD OWNER'S NAME SMITH TODD M
G OWNER ADDRESS GIADONE-SMITH CHRISTINA E 3 THEODORE DR LEOMINSTER MA TEL
01453
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL 0
PRINT
CLEARLY NEW CI RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO0
FIXTURES 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
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 Q OTHER OF INDEMNITY❑ BOND El
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 at 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 Koss LICENSE# 10377 SIGNATURE
MPQ MGF❑ JP❑ JGFE LPG'❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME David J Koss ADDRESS 36 WASHINGTON AVE,
CITY W YARMOUTH STATE MA ZIP 026732434 TEL
FAX CELL J 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