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HomeMy WebLinkAboutBLDG-22-003659 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '.N CITY YARMOUTH MA DATE December 30,202'.PERMIT# BLDG-22-003659 JOBSITE ADDRESS 16 HEADWATERS DR OWNER'S NAME SIDERIS MARK G OWNER ADDRESS SIDERIS MARYBETH 30 UNION STREET WATERTOWN MA 02472 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 FIXTURES FLOORS-r 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 - 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 ❑ OWNERS 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 at plumbing work and installations performed under the permit issued for this application will be in compliance with at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME David Houde LICENSE# 16673 SIGNATURE MP©MOP 0 JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: McDonnell Mechanical Services Inc ADDRESS. 79 School Street, CITY West Dennis STATE MA ZIP 026702445 TEL 5083940005 FAX CELL 5082463152 EMAIL S3lON M3IA32i NVld #111NH3d $ :33d ID 1114183d 3H1 SV S31183S NOIiVOIlddV SIHl ON SeA S3 LON N01133dSNI 1VNld /LINO 3Sf1 HOd 3OVd SIHl S3lON N011O3dSNI SVO HJf102f