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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"�1.L CITY Yarmouth , MA. DATE 9/22/11 PERMIT#C-12- 1 7 Z
JOBSITE ADDRESS 44 Strawberry Ln,Yarmouth Port OWNER'S NAME Paul White
OWNER ADDRESS: Same TEL: 508-362-5096 FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
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 a,
GENERATOR
°lei GRILLE
Q LABORATORY COCKS
MAKEUP AIR UNIT
Lt OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
C' UNVENTED ROOM HEATER
D WATER HEATER
1,4
INSURANCE COVERAGE 1
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES p NO ❑
I If you have checked YES,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 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
1`' Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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' CHECK ONE ONLY: OWNER 0 AGENT ❑
CI SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are • ac urate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application wi •- n co pH. e with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: Kevin Saunders LICENSE# 3860 S N G•E ,
COMPANY NAME: Seaside Gas Service Inc ADD SS: 67 elmsman Dr
CITY: Yarmouth Port STATE: m ZIP: 02675 FAX 508-362-2682
TEL: 508-400-0943 CELL: 508-400-0943 EMAIL: ISeasideGas@comcast.ne
MASTER❑ JOURNEYMAN 0 LP INSTALLER❑ CORPORATION g# PARTNE �'• '.7 ;an; LIE 0#
SEP 2 .7 2011
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