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HomeMy WebLinkAboutG-12-782 __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GASSaFITTING7WCORK ?-ki_ CITY 'Wes+ NurmallNI i MA DATE (e)I14120it..I PERMIT# JOBSITE ADDRESS // W/SIu%a Lance OWNER'S NAME 1 App,/S Ri'1;1 ' GOWNER ADDRESS /I hi/Sterica- Lan TEL • FAX TYPRINT CLEARLY OCCUPANCY TYPE COMMERCIAL❑ �DUEDUCATIONAL❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:[2 PLANS SUBMITTED: YES© NOD •. APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 EION$URNER . �115111I �J;; manes COOK STOVEaliiiiiiii',Ma MKS iiinniaailliniiiiniiiin DIRECT VENT HEATER DRYER REPLACE FRYOLATOR FURNACE1El II GENERATOR INER111111. II GRILLEi I IIiiiiIiIiIi POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT 11 ' TEST ) UNIT HEATER 1 II 1 UNVENTED ROOM HEATER I I 1, WATER HEATER I ' OTHER P,e', . ..111111I1ULflflfl!1fl 1 1 imam" essan , , INSURANCE COVERAGE I have a current Jlabillty Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY Q 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 Q AGENT Q 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 end that ell plumbing work and Installations performed under the permit Issued for this application will be In co chance with all Pert! t p Islon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME GERHARD ROBICHAUD LICENSE# 2753M IGN TURE pAejeli MP Q MGF 0• JP Q JGF❑ LPGI Q CORPORATION Q# 159 PARTNERSHIP©# LLC 0# COMPANY NAME: ROBIES ADDRESS 279 YARMOUTH RD - -- CITY HYANNIS STATE MA ZIP 02601 TEL 508.775.3083 FAX 508-534-1272 CELL 'EMAIL JROBIE1@VERIZION.NET R E C E I V F n I UN142012 )e. I GU RTMENi'4 4 ," - G By