HomeMy WebLinkAboutG-14-1082 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
111, CITY YARMOUTH , MA. DATE 06120114 PERMITI�
JOBSITE ADDRESS 100 LOOKOUT ROAD OWNER'S NAME CIPOLLA
OWNER ADDRESS: YARMOUTHPORT TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑�
FIXUTRES 7 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
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
1JN V€t'fTEB.ROOM HEATER--
WAMatHEATER IVED
JUN 24 2014
auILoINGaiti . cr4i INSURANCE COVERAGE
voacurrentlii6tirlity-insbrante policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES It NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY It OTHER TYPE INDEMNITY 0 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 0
SIGNATURE OF OWNER OR AGENT
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 Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws..- T
PLUMBERIGASFITTER NAME LEON E CLARK,JR. LICENSE# 11734-M SIGNATURE 2
COMPANY NAME: TC TYNDALL&CLARK PLUMBING AND HEATING , .. ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: m ZIP: 02660 FAX 508-385-9177
TEL 508-385-8868 CELL 508-367-1451 EMAIL
MASTER 0 JOURNEYMAN 0 LP INSTALLER 0 CORPORATION UI# PARTNERSHIP 0# LLC❑#