HomeMy WebLinkAboutBLDG-15-002199 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ra3Fi!, CITY WEST YARMOUTH MA DATE 10/23/14 PERMIT# I 'l9b /9t 60J1
JOBSITE ADDRESS 15 JERUSHA LANE OWNER'S NAME DOOLEY
GOWNER ADDRESS 15 JERUSHA LANE TELJ 617-839-3643 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ID RESIDENTIAL E]
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YESD NO❑+
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑+ OTHER TYPE INDEMNITY ❑ 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 ❑
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 b st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be' mpliance withall ertinen rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �n{_W
PLUMBER-GASFITTER NAME ADAM TRAYNER LICENSE# 3880 SI AT E
MP❑ MGF 0 JP❑ JGF❑ LPGI❑ CORPORATION Q# 173 PARTNERSHIP LLC❑#
COMPANY NAME: ROBIES HEATING&COOLING ADDRESS 279 YARMOUTH RD
CITY HYANNIS STATE MA ZIP 02601 TEL 508-775-3083
FAX 508-534-1272 CELL 774-836-5659 EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES