HomeMy WebLinkAboutbldg-19-002661 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
YARMOUTH 10/29/18
CITY MA DATE PERMIT# / Nr iF—°°,5Z661
31 BRAE BURN LANE GALLIGAN
JOBSITE ADDRESS OWNER'S NAME
GOWNER ADDRESS TEL 508 561 1735 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL•
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑■ PLANS SUBMITTED: YES❑ NO E
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER t
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
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I] NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY rill OTHER TYPE INDEMNITY IEl 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 co fiance with all Pert nt ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME DOUG LANGTRY LICENSE# 11305 IG U
MP❑■ MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑■ # 3081
COMPANY NAME AQUA SERVICES PLUMBING & HEATING ADDRESS 1268 ROUTE 28
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 774-470-1350
FAX 774-470-1351 CELL EMAIL DOUG-AQUA@COMCAST.NET
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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