HomeMy WebLinkAboutBLDG-19-002809 #4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY Yarmouth MA DATE 11/7/2018 PERMIT# /9 / -COAC
JOBSITE ADDRESS 22 Aarons Way L,ei OWNER'S NAME Louis Seminara j
GOWNER ADDRESS TEL FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL • EDUCATIONAL El 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
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE 1
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
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I 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 applicati e and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will in liance wi ertinent ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME j I LICENSE# 18252 (GNAT
MP MGF JP JGF r1 LPG! .1 CORPORATION # PARTNERSHIP # LLC # J
COMPANY NAME:David DuVerger ADDRESS 26 Dove Ln
CITY West Yarmouth STATE Ma ZIP 02673 TEL
FAX CELL 5089442027 EMAIL duverger26@comcast.net fib . : 't F E
NOV 07 201h I)"503EPARTMEVO
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