HomeMy WebLinkAboutBLDG-17-006564 ff 6 wlr7 r?cieYt
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY Yarmouth MA DATE 06/13/17 PERMIT# ..lj/ /7-00a' 1
JOBSITE ADDRESS 1 Ridgewood Road,Yarmouthport OWNER'S NAME Yvette Chamberland
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OWNER ADDRESS 1 Ridgewood Road,Yarmouthport TEL 415-577-9727 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-4 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
FIREPLACE 1
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1 11
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER _ -
OTHER
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 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 Pe ' ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws .
PLUMBER-GASFITTER NAME;J<evin J. Sullivan LICENSE# 13041 SIGNATURE
MP ' MGF i JP JGF LPGI CORPORATION #2433 PARTNERSHIP #
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COMPANY NAME: Ready Rooter, Inc ADDRESS P.O. Box 371..r._....
CITY Sandwich STATE MA ZIP 02563 ITEL 508-888 6055
FAX 508-888-0242 CELL S-0 - L i EMAIL kjs@readyrooter.com