HomeMy WebLinkAboutBLDG-15-000030 k 1` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'-:!LAW$ CITY yarme opthport MA DATE 7111114 PERMIT# 8' 030
JOBSITE ADDRESS 40 thachefshore rd OWNER'S NAME Randall,John
Cr OWNER ADDRESS TEL 508-362-9064 FAX
O TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL RESIDENTIAL DI
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: '0 PLANS SUBMITTED: YESQ NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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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 0
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 ❑
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
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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (.
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PLUMBER-GASFITTER NAME Edward Caswell LICENSE# 9119 SIGNATURE
MPO MGF❑ JP JGF❑ LPGI❑ CORPORATION❑. # 3655 PARTNERSHIP EP LLC 0#
COMPANY NAME: Cape Cod Gas Heat and Ac inc I ADDRESS 15 Jan Sebastian Dr*14 I
CITY Sandwich 1 STATE MA ZIP I02563 (TEd-508:539-WJ363'-C
FAX CELL EMAIL @capecodgas.com ‘ t_ °.,
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