HomeMy WebLinkAboutBLDG-21-002986 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE November 25,202( PERMIT# BLDG-21-002986
JOBSITE ADDRESS 72 SWIFT BROOK RD OWNER'S NAME MOONEY THOMAS M TRS
G OWNER ADDRESS MOONEY PATRICIA F TRS 72 SWIFT BROOK RD SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111
PRINT
CLEARLY NEW: ❑ 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
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
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❑
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 James Carabitses LICENSE# 11156 SIGNATURE
MP Q MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: ARS Boston ADDRESS. 300 Manley St.,
CITY West Bridgewater STATE MA ZIP 02379 TEL 5085889025
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