HomeMy WebLinkAboutBLDG-18-001163 cif MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
tjeg---." CITY Yarmouth MA DATE 08/30/2017 PERMIT# I,'� /7-/$d0//lo j
JOBSITE ADDRESS 80 Capt York Rd OWNER'S NAME Brad Jonson
GOWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
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 1
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER i
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 complia with all Pertinent provision of the _
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME JASON DREW LICENSE# J-30715 SIGNATURE
MP MGF JP i JGF LPGI CORPORATION # _ PARTNERSHIP # LLC #
COMPANY NAME: DREWS PLUMBING ADDRESS 6 AGASSIZ ST V_ _____y __,__ �,�_
CITY BREWSTER STATE MA ZIP102631 TEL 508-360-1400 E i
FAX CELL EMAIL ____
(� BUILDIN DEPARTM�N '
1_ BY ce 19 .k.