HomeMy WebLinkAboutG-14-153 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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="k-= CITY YARMOUTH , MA. DATE 08/15/13 PERMIT#
JOBSITE ADDRESS 183 EILEEN STREET OWNER'S NAME HENDERSON
GOWNER ADDRESS: YARMOUTHPORT TEL 508-479-7860 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:0 , REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0
FIXUTRES 1 FLOOR—. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE x
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 ROO •TER
WATER H • a O
eN I A 'S
1
/Ar,S ``\\(j,9 Lot 10141 INSURANCE COVERAGE
halt mos• -118111 s% ance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ❑] NO 0
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If 1 •te w ed YES please indicate the type of coverage by checking the appropriate box below.
LIABIUTY INSURANCE POUCY 0 OTHER TYPE INDEMNITY ❑ BOND ❑
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 9
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 application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 9Q� I ,
PLUMBER/GASFITTER NAME: LEON E CLARK,JR. LICENSE# 11734-M SIGNATURE
COMPANY NAME TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: m ZIP: 02660 FAX 508-385-9177
TEL 508-385-8868 CELL: 508-367-1451 EMAIL:
MASTER 0 JOURNEYMAN 9 LP INSTALLER❑ CORPORATION 0# PARTNERSHIP 9# LLC❑#
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