HomeMy WebLinkAboutG-14-1036 tielm4'7 /Zen Aeons,- 2n., vecier
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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"NL CITY Yarmouth MA DATE 6/9/214 PERMIT# kill- 109(
JOBSITE ADDRESS 44 Dartmoor Way OWNER'S NAME Parker
GOWNER ADDRESS same TEL 508.737.1457 FAX
Irfrn� pTYPEOR RINT OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL RESIDENTIAL El
p{ CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:CI PLANS SUBMITTED: YES NO0
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BOILER
BOOSTER I
CONVERSION BURNER I ,
COOK STOVE x _
DIRECT VENT HEATER — - � - :WS IP
DRYER
FIREPLACE
FRYOLATOR
FURNACE _ _
GENERATOR
GRILLE
INFRARED HEATER i _
LABORATORY COCKS i
MAKEUP AIR UNIT
OVEN — — -
—
POOL HEATER
ROOM ISPACE HEATER ;
ROOF TOP UNIT i, „ '
TEST
UNIT HEATER
-UN VENTEDROOMHEJ TEF -
WATER FIEATER3 V t. U
OTHER_ s Pi.e $2 x - - —-
CIP66 2 "
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UILUINLrcl MLN i
INSURANCE COVERAGE
haveaturreaility insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO ❑
I IF YOU 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 accurst to the best of my knowledgen
and that all plumbing work and installations performed under the permit issued for this application will be in compli with n e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Charles Stockdale LICENSE#12 -6-1 SIGNATURE
MP❑ MGF❑ JP a JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME: CLS Plumbing ADDRESS 256 Mayfair Rd.
CITY S.Dennis STATE MA ZIP 02660 TEL 508.398.2843
FAX CELL 774-208-1613 EMAIL
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