HomeMy WebLinkAboutBLDG-15-002974 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA. DATE 11/20/14 PERMIT#,%t*/c UD297y
JOBSITE ADDRESS 94 WHARF LANE OWNERS NAME WANTANABE
CJ OWNER ADDRESS: YARMOUTHPORT TEL: FAX1
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑�
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CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑1 PLANS SUBMITTED: YES 0 NO ii
FIXUTRES 1 FLOOR-6 Bsmt 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
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST -
UNIT HEATER
CidtNOVH26 014 `�D/
SUILDI NC Tr4E IT INSURANCE COVERAGE
°y
have a currentJiabdrty insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ❑] OTHER TYPE INDEMNITY ❑ BOND 0
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.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
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 appli 'on will be in pli e with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTER NAME: LEON E CLARK,JR. LICENSE# 11734- SIGNATURE
COMPANY NAME TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: MA ZIP: 02660 FM: 508-385-9177
TEL: 508-385-8868 'CELL: 508-367-1451 EMAIL:
MASTER 0 JOURNEYMAN 0 LP INSTALLER❑ CORPORATION CI# PARTNERSHIP 0# LLC❑#
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