HomeMy WebLinkAboutG-13-110 __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'__"1—• CITY YARMOUTH , MA. DATE 06/17/13 PERMIT# bli—11(0
JOBSITE ADDRESS 25 ROUTE 6A OWNER'S NAME GARREFFI
GOWNER ADDRESS: YARMOUTHPORT TEL 508-897-9325 FAX:,
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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
DIRECT VENT HEATER
DRYER •
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER r
ROOM ISPACE HEATER Ir
ROOF TOP UNIT T
TEST 111 J'Jr: r,
UNIT HEATER ;.013
UNVENTED ROOM HEATER
WATER HEATER x DUILBy_ DINGO n l
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO 0
If you have checkedYf,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 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. rti f A.tth vt
PLUMBERIGASFITTER NAME: LEON E CLARK,JR. LICENSE# 1173441 SIGNATURE (•(
COMPANY NAME: TC TYNDALL 8 CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: In ZIP: 02660 FAX 508-385-9177
TEL: 508-385-8868 CELL: 508-367-1451 EMAIL
MASTER 0 JOURNEYMAN❑ LP INSTALLER❑ CORPORATION[I]# PARTNERSHIP❑# LLC❑#
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