HomeMy WebLinkAboutBLDG-21-002798 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
k4__` CITY YARMOUTH
MA DATE November 17,202( PERMIT# BLDG-21-002798
JOBSITE ADDRESS 150 GREAT WESTERN RD OWNER'S NAME HAYS JOHN L
G OWNER ADDRESS HAYS DEBORAH A 150 GREAT WESTERN RD SOUTH YARMOUTH MA 02664-2205 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Ej
PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES ❑ 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
GENERATOR ,
GRILLE
INFRARED HEATER ,
LABORATORY COCKS
MAKEUP AIR UNIT ,
OVEN
POOL HEATER 1
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER ,
OTHER
t
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 john Downey LICENSE# 32070 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑#
COMPANY NAME: ADDRESS. 76 swift Brook Rd,
CITY South Yarmouth STATE MA ZIP 02664 TEL
FAX CELL EMAIL
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