HomeMy WebLinkAboutBLDG-21-001461 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
. ) CITY F\RMOUTH MA DATE September 22,202 PERMIT# BLDG-21-001461
JOBSITE ADDRESS 757 WILLOW ST OWNER'S NAME SUTHERLAND BARBARA H TRS
OWNER ADDRESS SUTHERLAND PETER T 757 WILLOW ST SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: [I RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑
FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER 1
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 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 Plumbirg Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME David Houde LICENSE# MA SIGNATURE
MP❑ MGF ❑ JP❑ i,GF❑ LPGI ❑ CORPORATION 0 # MA PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: McDonnell Mechanical Systems Inc ADDRESS. 79 School Street,
CITY West Denniis STATE MA ZIP 02670 TEL 5083940005
FAX 5083945050 CELL 5082463152 EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
C1ji 7/z J?o'd 0 G`S THIS APPLICATION SERVES AS THE PERM ❑ ❑ 11j 11 z/ /t f,1 ,-p
FEE:$ PERMIT# Ngf C/G G/=S
PLAN REVIEW NOTES