HomeMy WebLinkAboutG-19-5870 _R 0,..01 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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®;FI CITY Yarmouth _ _J MA DATE;4/12/2019 _ PERMIT# 7 i,R , .I-,
JOBSITE ADDRESS 61 Kate's Path _ — l OWNER'S NAME ;Goetz _ ; '?
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OWNER ADDRESS I same
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL , `, RESIDENTIAL; 1 z "1 ,'A',R7ME T
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CLEARLY NEW: - RENOVATION:%] REPLACEMENT:F 71 PLANS SUBMITTED: YES NO "__1 -
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOILER �- � �;=i
CONVERSION BURNER i I I 1
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DIRECT VENT HEATER �' '' �' 1
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FIREPLACE rinninsairig 1FRYOLATORFURNACE I~ � aGENERATOR 1s
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INFRARED HEATER
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OVEN I '1 _IhilPOOL HEATER ____wROOM/SPACE HEATER ii,„,,,,,,,
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UNVENTED ROOM HEATER � i Enna !111.1M �WATER HEM ATER �
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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 1' NO '__.
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 7i OTHER TYPE INDEMNITY r-1 BOND L
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 Li AGENT i i
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 f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp.I.nce wi ertin t • n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME t Charles Stodcdale __;LICENSE#!24526 !' SIGNATURE
MP T_ MGF%' JP . JGF ___l LPG111 1 CORPORATION 1#i PARTNERSHIP #I _ LLC'___.J#;mm
COMPANY NAME Charles Stodtdale 1 ADDRESS 256 Mayfair Rd '
CITY ;S.Dennis STATE MA ZIP{02660 ITEL'508-398-2843 1
FAX 1 i CELL;774-208-1613 IEMAIL, 1
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