HomeMy WebLinkAboutBLDG-15-001666 1 € MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
i` M CITY Yarmouth • MA DATE 10/8/14 PERMIT# sea-15=00a�iQ
;7,,die JOB SITE ADDRESS 17 Bent Bluff Lane - OWNER'S NAME Mary Browne
•
G OWNER ADDRESS 17 Bent Bluff Lane TEL 530-913-7437 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL El INSPECTED 0
PRINT
CLEARLY NEW RENOVATION: REPLACEMENT:❑ CheCk# PLANS SUBMITTED-YES 0 NO®
APPLIANCES- FLOORS- BSM I 2 3 4 5 6 7 8 9 to I I 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 I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
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BYIILDINGf�'9QA„jgTMENT
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES® NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY ® 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
PLUMBER-GASFITTER NAME
CHECK ONE ONLY:OWNER 0 AGENT 0
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 compliance with all Petnent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASFITTER NAME Forrest Ferrill LICENSE# 9964 ez/r
SIGNATURE
MP ® MU 0 JP 0 JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME - ADDRESS 10 Orchard Way
CITY Sandwich STATE MA ZIP 02563 - TEL 508-420-0700
FAX 508-681-0693 CELL 508-420-0700 EMAIL forrest@frogmendivers.com
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