HomeMy WebLinkAboutBLDG-17-002688 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`'-" i= CITY Yarmouth MA DATE 11/14/2016 PERMIT# 'i A r IT—CM
JOBSITE ADDRESS 0117 Pawkannawkut Dr OWNER'S NAME -J hn Aubin
GOWNER ADDRESS I TO FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL fl RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION:; , REPLACEMENT: PLANS SUBMITTED: YESD NO❑
APPLIANCES-1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ._
BOOSTER
CONVERSION BURNER in I
COOK STOVE ■ 111111 1111111111 ____■ ■■�
DIRECT VENT HEATER 2
III
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR 1111111111.
111111115E11111111111
GRILLE
INFRARED HEATER ®MIIIIIIIIIIIIIIIIMIIIIIIIIIII
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT L
TEST0 I'
UNIT HEATER //,
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER j
vII,
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 i NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i 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 a ue and acc e to the b of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be' pliance wi 'CI'ertinen rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME David DuVerger LICENSE# 18252 gl'id, ' SI NAT
MP MGF❑ JP E JGF❑ LPGI
❑ CORPORATION Of 1 PARTNERSHIP Elfin-- LLC #
COMPANY NAME. David DuVerger I ADDRESS 0 Dove Ln
I CITY West Yarmouth
f STATEI Ma IZIP 02673 ITEL J ,
FAX I CELL 5089442027
EMAIL.1)(,,f f�g_4./fiZ a,6 Q ev fr e46.7. ,1vi--
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