HomeMy WebLinkAboutBLDG-19-001430 __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'"Ii_ CITY Yarmouth MA DATE 9/6/18 PERMIT# /1.406/9-00lrt
JOBSITE ADDRESS 74 Hatch Road OWNER'S NAME Ed Smith
G. OWNER ADDRESS TEL 860-307-3452 1FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER 7
CONVERSION BURNER 1 i I I I I _. _.
COOK STOVE
DIRECT VENT HEATER i I _ '- I, r lc -11 if-
DRYER
FIREPLACE
FRYOLATOR —Sia Me la a �-
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INFRARED HEATERr IRO 5 , ,i, F
LABORATORY COCKS Jason i _._ _ si man
MAKEUP AIR UNIT al ,11111111111111101111111111111111, 11111{1r.tinir.w ZL w,r e
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POOL HEATER En
ROOM I SPACE HEATER
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ROOF TOP UNIT '
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UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER 1 �-S' 'e' R ,Ra
OTHER 1-'� Maal . Re m „
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 ❑ 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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Stephen D.Ewing LICENSE# 15281 SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPG'❑ CORPORATION Q# 3672 PARTNERSHIP 0# LLC❑#
COMPANY NAME: Edgewater Plumbing&Heating ADDRESS P.O.Box 656 •
CITY Sagamore STATE MA ZIP 02561 TEL 508-317-9680
FAX CELL 508-737-0077 EMAIL stevecedgewaterplumbinginc.com
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