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HomeMy WebLinkAboutBLDG22-002020 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY YARMOUTH MA DATE 'October 08,2021 'PERMIT# BLDG-22-002020 JOBSITE ADDRESS 108 POINSETTIA DR OWNER'S NAME STANLEY THOMAS M G OWNER ADDRESS C/O THOMAS STANLEY 19 NEIGHBORS LN WALTHAM MA 02453 TEL TYPE.OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:©' REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0 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 1 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 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 0 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 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 as Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'David Houde 'LICENSE# 116673 I SIGNATURE MP©MGF❑JP❑ JGF❑ LPG'0 CORPORATION❑#I ' PARTNERSHIP ❑# LLC❑#I COMPANY NAME: 'McDonnell Mechanical Services Inc 'ADDRESS. 179 School Street, I CITY 'West Dennis 'STATE MA ZIP I02670 'TEL 15083940005 FAX 1 I CELL 15082463152 I EMAIL 1 S310N NVId #IIWd3d $ :33d ❑ ❑ IIIVEd 3H1 SV S3AN3S NOIlVOIlddV SIHl oN seA S310N N01103dSNI IYNIJ AlN0 3Sf1 Z10103dSNJNOJ 30Vd SIHl S310N N011O3dSNl SdJ HJf10m