HomeMy WebLinkAboutG-19-2891 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
di CITY Yarmouth MA DATE _111912018___
;1 PERMIT# ,4Db/9 COW)
JOBSITEADDRESS_3G_aft 4'%r- i& __ OWNER'S NAME 1/4/10IMOY4..viz._iROfiCt
G OWNER ADDRESS JG_GYior Ryder" Rd_- - TEL 6-6iFa/ `Y3L!FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL i RESIDENTIAL I
PRINT
CLEARLY NEW: ! RENOVATION: !! REPLACEMENT: _I PLANS SUBMITTED: YES _.-_( NO__J
APPLIANCES 7 FLOORS-, ESM 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
OVEN
POOL HEATER
ROOM!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 I±J NO _I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .+.1 OTHER TYPE INDEMNITY . I 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 __J
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 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 comp ce w all -> inent pr. ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,✓ O% A
PLUMBER-GASFITTER NAME Peter J.Hassett LICENSE# 11682___1 G�� SIGNATURE
MP +.J MGF ._1 JP ! JGF ! LPG' _i CORPORATION +i# 3506 PARTNERSHIP_'# ; LLC #
COMPANY NAME Hassett Plumbing and Heating Inc. _f ADDRESS 8 Skipper Lane j
CITY Yarmouth Port STATE MA_1 ZIP 02675___,_.,J TEL 508-744-7555
FAX .�__ 1 CELL 508-237-2175 !EMAIL peterjhassett@gmail.com
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