HomeMy WebLinkAboutG-14-010 �_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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sNi=5 CITY YARMOUTH PORT MA DATE 7/2/2013 PERMIT# &8-0/0
JOBSITE ADDRESS 30 Tranquail Trail OWNER'S NAME Dwain Dadoly
GOWNER ADDRESS SAME TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOD
APPLIANCES t FLOORS BSM 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 "�
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT r r
OVEN
POOL HEATER
ROOM I SPACE 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 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY WA OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the clrlseE&Et iai[tl[e Ir sJIr nee coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature .n is perm e this requirement
1 3 2013 CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT MI/ yd 4 ,.
I hereby certify that all of the details and Information I hay . • •`e?�i� ; "•) I., p application are true a X1,2 rate to the best of my knowledge
and that all plumbing work and Installations performed un =` ra 7 Jam'ya. on will be In compli z• ���nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the Genera =ws.
_SaPLUMBER-GASFITTER NAME JASON DREW LICENSE# J-30715 SI 'ATURE
MP 0 MGF 0 JP 0 JGF 0 LPG!0 CORPORATION 0# PART r SHIP D# LLC❑#
COMPANY NAME: DREW'S PLUMBING ADDRESS 6 AGASSIZ ST
CITY BREWSTER STATE MA ZIP 02631 TEL 508-367.5739
FAX CELL EMAIL