HomeMy WebLinkAboutBLDG-18-007298 A� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-? _d CITY Yarmouth MA DATE 06/25/2018 PERMIT# Per/y'-OC17acQ,i
JOBSITE ADDRESS 34 Lookout Rd OWNER'S NAME Kevin ryan
GOWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL El
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CLEARLY NEW:❑ RENOVATION:Q REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LU 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 Q 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 perfomied under the permit issued for this application will be in corn nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME JASON DREW LICENSE#P:557-1- SIGNATURE
MP 0 MGF❑ JP Q JGF D LPGI❑ CORPORATION p# PARTNERSHIP❑# J LLC p# J
COMPANY NAME:DREW S PLUMBING ADDRESS 6 AGASSIZ ST
CITY BREWSTER STATE MA ZIP 02631 TRi5t38{36 74fJ j E_D
FAX CELL EMAIL
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BUILDING DEPA i •S
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