HomeMy WebLinkAboutBLDG-18-003851 //)/7' .' f /:
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1E40 CITY YARMOUTH MA DATE January 07, 20' PERMIT# BLDG-18-003851
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JOBSITE ADDRESS 21 WOODBINE AVE OWNER'S NAME HACHADOURIAN JEREMIAH
G OWNER ADDRESS 21 WOODBINE AVE WEST YARMOUTH MA 02673 TEL
I1'PL OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRIM'
CLEARLY NEW El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 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 I _
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES El NO❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY❑ BOND El
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.
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 Anthony Cooper LICENSE# 32048 SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: ANTHONY J COOPER ADDRESS 66 CHUCKLES WAY,
CITY MARSTONS MLS STATE MA ZIP 026481583 TEL
FAX CELL EMAIL
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