HomeMy WebLinkAboutG-19-969 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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5.y '� CITY YARMOUTH MA. DATE 8/10/18 PERMIT# 4 I7 767
JOBSITE ADDRESS 447 ROUTE 6A OWNER'S NAME MICHAELS
GOWNER ADDRESS: YARMOUTHPORT TEL: FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL I
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:fr��dpg�I h S BMITTED: YES❑ NO 0FIXUTRES 1 FLOOR-• Bsmt 1 2 3 4 5 7( 8 9 10 11 12 13 14
BOILER \
BOOSTER \ Jt'�
CONVERSION BURNER ���✓✓��111 v„'
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
UNVENTED ROOM HEATER _
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY El 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 • •n will be in compliance
all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , p
PLUMBERIGASFITTER NAME: LEON E CLARK,JR. LICENSE it 11734-M SIGNATURE l/�t
COMPANY NAME: TC TYNDALL 8 CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: fl ZIP: 02660 FAX 508-385-9177
TEL: 508-385-8868 CELL: 508-367-1452 EMAIL:
MASTER❑t JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
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