Loading...
HomeMy WebLinkAboutBLDG-22-002394 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK " —a` ...o"^ JOBSITE ADDRESS 392 STATION AVE OWNERS NAME LIKENS CATHERINE G EXC G OWNER ADDRESS C/O JOHN&CATHERINE LIKENS 6573 EATON ST HOLLYWOOD FL 33024-7652 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE , DIRECT VENT HEATER DRYER 1 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 INSJRANCE POLICY❑ OTHER OF INDEMNITY BOND 0 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 Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME leon clerk jr LICENSE# MA SIGNATURE MP El MGF❑JP❑ JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME TC TYNDALL&CLARK;LUMBING&HEAT ADDRESS, 18 ATLANTIC AVE, CITY SOUTH DENNIS STATE MA ZIP 02660 TEL 5083858868 FAX CELL EMAIL S310N M31A321 NV1d #±IW2d3d $ :33d 613 /7/t7/7/ —110 ❑ ❑ II141213d 31-11 SV S3AN3S NOIlV011ddd SIHl ON SGA S310N N01103dSNI 1VNId AlN0 3Sf1 2:10103dSNI elOd 30Vd SIH1 S310N N01103dSNI SYJ HOflO