HomeMy WebLinkAboutBLDG-19-001913 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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14_ CITY Yarmouth i MA DATE 8 PERMIT# fi�i06/j—C7�
JOBSITE ADDRESS; y Tern Rd OWNER'S NAME Sheila ForesterG
OWNER ADDRESS Same i TELF FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 3 , RESIDENTIAL
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CLEARLY NEW: RENOVATION:L REPLACEMENT:!F�, PLANS SUBMITTED: YES A NO?
APPLIANCES-1 FLOORS—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ,��
BOOSTER r1111111.
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CONVERSION BURNER
COOK STOVE ry
DIRECT VENT HEATER ® ?
DRYER TAW'
FIREPLACE I a - jag I.
FRYOLATOR ® r.. '
FURNACE 7
GENERATOR I
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INFRARED HEATER WWI
LABORATORY COCKS OM= jot a
MAKEUP AIR UNIT i .__.. —t ',I
OVEN _�,. __.
POOL HEATER
ROOM I SPACE HEATER ® i; f �'
ROOF TOP UNIT ( g
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UNIT HEATER 111111111111MENn j ! 1 I..
UNVENTED ROOM HEATER
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WATER HEATER _ ____ _, _
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INSURANCE COVERAGE l
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES f 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 f
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 .p 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 the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME[JASON DREW LICENSE# J-30715 ATURE
MP L MGF LI JP171 JGF 1 LPGI Li CORPORATION # PART SHIP LJ# � � ' LLC%�#L
COMPANY NAME.DREW'S PLUMBING ADDRESS 6 AGASSIZ S___
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CITY BREWSTER : 6. . _
STATE aMA ZIP102631 TEL` 0 1400 a�
FAX' j CELL EMAIL
OCT 01 2018
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