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HomeMy WebLinkAboutBLDG-22-002032 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK A`kt,,,,,, BLDG-22-002032 iI CITY YARMOUTH MA DATE October 08,2021 PERMIT# JOBSITE ADDRESS 1 DUNSTER PATH OWNER'S NAME HURLEY MARK G OWNER ADDRESS JURLEY JANE A 1 DUNSTER PATH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El FIXTURES FLOORS--. 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 OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF 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. 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 LEON CLARK,JR LICENSE# MA SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: TC TYNDALL&CLARK PLUMBING&HEAT ADDRESS. 18 ATLANTIC AVE., CITY SOUTH DENNIS STATE MA ZIP 02660 TEL 5083858868 FAX CELL EMAIL S310N MIA Ndld #±H'N 9d $:33d El El iJ1Al2:13d 3H1 SV S3AH3S N011VOIlddV SIHJ oN seA S310N N0I103dSNI lYNId AlNO 3Sfl 2101.03dSNI 210d 30Vd SIHI SLON N01103dSNI Sd0 HJl02f