HomeMy WebLinkAboutBLDG-17-005079 ---�ewr
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
14W, CITY Yarmouth MA DATE 04/03/2017 PERMIT# / hll� /7-40 b071
JOBSITE ADDRESS 190 Forest Rd OWNER'S NAME Jack Lynos
GOWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 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 _
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
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 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER-GASFITTER NAME JASON DREW LICENSE# J-307151 SIGNATURE
MP MGF JP JGF i LPGI CORPORATION `# PARTNtRSHIP # LLC #
COMPANY NAME: DREWS PLUMBING I ADDRESS 16 AGASSIZ ST
CITY BREWSTER STATE MA !ZIP 02631 TEL 508-360-1400
FAX CELL EMAIL
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