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Home My WebLink AboutBLDG-21-003479 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY YARMOUTH MA DATE December 17,202( PERMIT# BLDG-21-003479 JOBSITE ADDRESS 84 LAKEFIELD RD OWNER'S NAME WALLACE JOAN G OWNER ADDRESS 84 LAKEFIELD RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 - 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 1 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 ❑ 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 Kevin Mccullough LICENSE# 30511 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: KEVIN M MCCULLOUGH ADDRESS. 91 GOVERNOR BRADFORD RD, CITY BREWSTER STATE MA ZIP 026312805 TEL FAX CELL EMAIL ' /1,z/�i — 1-2-r S310N M31A32f N did ,4,-3.-4,, �Pti � #±IW213d $ :333 ❑ ❑ 111A213d 3E11 SV S3Ab3S N011` OIlddV SIHI oN SO) S310N N01103dSNI 1VNH ,ONO 3Sl 2i0103dSNI 2IOd 39Vd SIHI S310N N01103dSNI SVJ HJf102' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: Y `+Iv\0.1-V\ MA. DATE: ?(.130 P RMIT# JOBSITE ADDRESS: b R LAY--Q c-NA S, OWNER'S NAME: G OWNER ADDRESS: 75`"� ��►�\.& TEL: '?,4 -v tS 3FAX: TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:X RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ APPLIANCESI. FLOOR—+ Bsmt 1 — 2 3 4 5 6 7 8 9 10 11 12 13 14 -BOILER BOOSTER CONVERSION BURNER COOK STOVE - I DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE VI INFRARED HEATER ' LABORATORY COCK - _ _ _ _ kMAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER �.I ROOF TOP UNIT fi TEST UNIT HEATER _ ,C 14� C) t.� UNVENTED ROOM HEATER _ WATER HEATER 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 have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0 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 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are e and a to to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will pliance with all Pertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: .RU eV y �C�;\r cv LICENSE# It S ATURE COMPANY NAME: VvtZ.. 4 � � �,,C �� \ ADDRESS: 91 C'�` �;'� 7 A • �v" CITY: STATE: ZIP: ��; FAX: TEL: tio \'l CELL:?7y- -1�5-,3 it � EMAIL: �nCCG.:\\t��:�� MASTER 0 JOURNEYMAN ei LP INSTALLER❑ CORPORATION( # PARTNERSHIP 0# LLC❑# c wit. AD..2e- :