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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'1 CITY yamlouthport MA DATE 10/22/14 PERMIT# / IJb/� "oZ(70 7
JOBSITE ADDRESS 181 Thacher Shore rd OWNERS NAME Carel Condon
G OWNER ADDRESS TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL✓
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:✓ PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
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/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE p-cr d3 (6
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.14 YES ✓ NO
IIFYOU CHECKED YES,PLEASEINDICATE THE TYPE OFCOVERAGE BYCHECKING THE APPROPRIATE BOX BELOW ) �'BUILDING Dl1t,",PAFZTtyENT
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LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY BOND 50DO
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 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.
PLUMBER-GASFITTER NAME Wafter Nye LICENSE#32083 SIGNATURE
MP MGF JP V JGF LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:Nye Plumbing and heating ADDRESS 1 canary In
CITY West yarmouth STATE MA ZIP 02673 TEL 508-246-3349
FAX CELL EMAIL
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