HomeMy WebLinkAboutBLDG-18-000315 '1\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY YARMOUTH MA DATE 7/11/2017 PERMIT# />L`
JOBSITE ADDRESS 21 CIRCUIT ROAD EAST OWNER'S NAME NANCY BRENNAN
GOWNER ADDRESS 504 BEACON ST,APT 53, BOSTON, MA TEL 617-895-9555 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL ■❑
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CLEARLY NEW: ❑ RENOVATION: ❑■ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑■
APPLIANCES Z 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 1
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 ❑■ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑■ OTHER TYPE 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.
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 the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia e with a n rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. >j
PLUMBER-GASFITTER NAME DOUG LANGTRY LICENSE# 11305 S ATURE
MP❑■ MGF❑ JP El JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP E 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