HomeMy WebLinkAboutBLDG-18-003161 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"1:1_— , CITY Yarmouth MA DATE 11/21/2017 PERMIT# ' &-/„"°c I6/
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JOBSITE ADDRESS 8 Reflection Way l OWNER'S NAME Joseph Mellow
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OWNER ADDRESS Same `TEL, FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: ' RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 1 r FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ,
BOOSTER
CONVERSION BURNER ;
i
COOK STOVE ,
DIRECT VENT HEATER '
DRYER
FIREPLACE
FRYOLATOR __
FURNACE
GENERATOR 1
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT i
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT CA& (37"/
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER _
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY v 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 ith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME[JASON DREW LICENSE# J-30715 IGNATURE
MP MGF ._., JP JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:IDREVV'S PLUMBING ADDRESS 6 AGASSIZ ST
CITY BREWSTER STATE MA ZIP 02631 TEL 508-360-1400
FAX CELL EMAIL
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