HomeMy WebLinkAboutbldg-17-000950 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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®"T F CITY Yarmouth MA DATE 07/20/2016 PERMIT# /'mil er-/T"1dv956
JOBSITE ADDRESS 24 Boxberry Lane OWNER'S NAME Malcolm Morse
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OWNER ADDRESS TEL FAX'
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ] RESIDENTIAL
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CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
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 AG .T
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. h- .-- of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit al 'e n:• irov .ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. d
PLUMBER-GASFITTER NAME'ALEX BRAGA LICENSE# 15668 SIGNATURE
MP MGF JP JGF LPGI CORPORATION # 3618 PARTNERSHIP # LLC #
COMPANY NAME: BRAGA BROS INC ADDRESS 110 BREEDS HILL ROAD UNIT 5
CITY HYANNIS STATE MA ZIP 02601 TEL 508-827-4260
FAX 508-957-2960 CELL 774-487-0199 EMAIL BRAGABROS@COMCAST.NET