HomeMy WebLinkAboutBLDG-17-005045 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
S-1111,2
ell CITY Larmouth MA DATE1412/2017 PERMIT# Z--/7
JOBSITE ADDRESS 2 Mill Ln.Yarmouthport 'OWNER'S NAME Maker_
GOWNER ADDRESS ,same I TELL IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL] EDUCATIONAL[I RESIDENTIAL El
PRINT
CLEARLY NEW:[ RENOVATION:El REPLACEMENT: .❑ PLANS SUBMITTED:YES I—INO
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 5 7 8 9 10 11 12 13 14
BOILER
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 ISPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER Gas main pipe replacement x
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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❑
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 ace rate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co 913 'sion of the
Code
Massachusetts State Plumbing and Chapter 142 of the General Laws. / -, r
PLUMBER-GASFITTER NAME shades Stockdale LICENSE# 24526 '-" SIGNATURE
MP MGFIT JPI71 JGF! LPGI CORPORATION[# PARTNERSHIP❑#I LLC❑!I
COMPANY NAME CLS Plumbing ADDRESS 256 Mayfair Rd.
CITY S.Dennis -- STATE MA ZIP 02660 TEL 508-398-2843
FAX ] LI774-208-1613 E
[ APR 03 2017 I I
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