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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ts-r CITY Yarmouth MA DATE 7/25/2018 PERMITS /WIT/ -4470v�Li f
JOBSITE ADDRESS 18 Wildflower Ln. OWNER'S NAME Regan
GOWNER ADDRESS same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NOD
APPLIANCES 7 FLOORS-. 85M 1 2 3 4 5 6 7 8 ' 9 10 11 12 13 14
BOILER • I
BOOSTER '
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CONVERSION BURNER I T 1 M I I 9
COOK STOVE 1 f�
DIRECT VENT HEATER '1 I I Y I
DRYER I I i IS I f II
FIREPLACE 7 N
FRYOLATOR `I - r I-- +r '
FURNACE 1 f a 4
GENERATOR NI -
GRILLE - �I
INFRARED HEATER 1 y I f IS
LABORATORY COCKS I i 1 '
MAKEUP AIR UNIT I H 1 I
OVEN I I f A
POOL HEATER 1 I
ROOM/SPACE HEATER I I 1 I
ROOF TOP UNIT N - _
TEST r
UNIT HEATER I I I I III
UNVENTED ROOM HEATER I i I
WATER HEATER I I
OTHER rrrI II 11 I 1 I
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of M LMT, ryEJS a NO 6
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL W �.- J
UABILITYINSURANCE POUCY ❑ OTHER TYPE INDEMNITY ❑ BY DBUAUMU1.EPAFt-rMENT
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.
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r ` CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 •M of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp!' ��e r -of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Charles Stockdale LICENSES 24526 I' SIGNATURE
MP❑ MGF❑ JP❑+ JGF❑ LPGI❑ CORPORATION❑S PARTNERSHIP❑t LLC❑S
COMPANY NAME: Charles Stockdale ADDRESS 256 Mayfair Rd.
CITY S.Dennis STATE MA ZIP 02660 TEL 508-398-2843
FAX CELL 774-208-1613 EMAIL
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