HomeMy WebLinkAboutG-13-1061 •
i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
afar CITY West Yarmouth MA DATE 612/2013 PERMIT# 4671-/�OG/
JOBSITE ADDRESS 44 Circuit Rd North OWNER'S NAME Cyndy Warner
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G OWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:ID RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOD
APPLIANCES? FLOORS--• BSM I 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER 'i
DRYER
FIREPLACE , - -
FRYOLATOR j u ti
FURNACE . y n
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS • rq
MAKEUP AIR UNIT
111
OVEN
POOL HEATER
ROOM ISPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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,-ccurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compl + ith ent provision of the
Massachusetts State Plumbing Code end Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Jason Drew LICENSE# J-30715 SI ATURE
MP D MGF❑ JP❑+ JGF 0 LPG'❑ CORPORATION❑# PART ERSHIP❑# LLC❑#
COMPANY NAME: Jason Drew ADDRESS 6 Agassiz St
CITY Brewster STATE MA ZIP 02631 TEL 508-367-5739
FAX CELL EMAIL
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