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BLDG-23-002609 #B MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r�' ?F, CITY YARMOUTH MA DATE November 10,202; PERMIT# BLDG-23-002609 JOBSITE ADDRESS /Z d 7.-,oei OWNER'S NAME TYNDALL JEFFREY AND KARIN G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 12 PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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 LEON CLARK,JR LICENSE# 11734 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ITC TYNDALL&CLARK PLUMBING&HEAT ADDRESS. 118 ATLATNIC AVE, CITY SOUTH DENNIS STATE MA ZIP 02660 TEL 15083858868 FAX CELL EMAIL Ikaren(a,tcplumbinq.net MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK gyp;_-•—c� - "ALF CITY YARMOUTH MA. DATE 11/9/22 PERMIT# JOBSITE ADDRESS 12B TUPELO RD SOUTH YARMOUTH I OWNER'S NAME TYNDALL Cj OWNER ADDRESS: 12A TUPELO RD SOUTH YARMOUTH I TEL: 508-367-1452 I FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:Q REPLACEMENT:El PLANS SUBMITTED: YES❑ NO ID FIXUTRES 1. FLOOR—, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑� NO El If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El 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 El AGENT ❑ 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 appli 'on will be in comp�ith Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: LEON E CLARK,JR. LICENSE# 11734-M IGNATURE COMPANY NAME: TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE CITY: SOUTH DENNIS STATE: L MA I ZIP: 02660 FAX: 508-385-9177 TEL: 508-385-8868 CELL: 508-367-1452 EMAIL: karen@tcplumbing.net MASTER 0 JOURNEYMAN El LP INSTALLER El CORPORATION 0# ]PARTNERSHIP❑# LLC 0#