HomeMy WebLinkAboutBLDG-18-000047 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ki_ CITY Yarmouth MA DATE 6/29/17 PERMIT#/ 496/ OdOo
JOBSITE ADDRESS 45 Rune Stone Road l OWNER'S NAME Calarese
GOWNER ADDRESS York Construction TEL 774-200-1889 iFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL r---t EDUCATIONAL RESIDENTIAL
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CLEARLY NEW: : RENOVATION: REPLACEMENT:[ PLANS SUBMITTED: YES[] NO
APPLIANCES 1 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 t .. f'
ROOF TOP UNIT
TEST
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 fl
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 4F Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Stephen D.Ewing LICENSE# 15281 SIGNATURE
MP / MGF JP JGF LPG' CORPORATION # 3672 PARTNERSHIP # LLC # J
COMPANY NAME: Edgewater Plumbing&Heating I ADDRESS P.O.Box 656
CITY Sagamore STATE MA ZIP 02561 TEL 508-317-9680
FAX CELL 508-737-0077 EMAIL steve@edgewaterplumbinginc.com