HomeMy WebLinkAboutG-14-198 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
et
<=-" _ = CITY YARMOUTH , MA. DATE 08130113 PERMIT# L- Y lb-/7b
JOBSITE ADDRESS 103 POINTSETIA DRIVE OWNER'S NAME KATSORAS
GOWNER ADDRESS: SOUTH YARMOUTH TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:9 RENOVATION:9 REPLACEMENT:0 PLANS SUBMITTED: YES 9 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 ROOM HEAT_s_„„,��7
WATER tragit
nEP442613 ,
1HG 7�' INSURANCE COVERAGE
I
have a cul . 4 le�Qi r . cy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO 9
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUCY 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 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 application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. art in- F 12! r
PLUMBERIGASFITTER NAME LEONE CLARK,JR. LICENSE# 11734-M ,SIGNATURE /n
COMPANY NAME: TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE -
CITY: SOUTH DENNIS STATE: Q ZIP: 02660 FAX 508-385-9177
TEL: 508-385-8868 CELL: 508-367-1451 EMAIL
MASTER 0 JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# ]PARTNERSHIP 0 it LLC❑# J/ .�n�