HomeMy WebLinkAboutBLDG-15-001492MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY YARMOUTH MA. DATE 09/22/14 PERMIT
JOBSITE ADDRESS 220 SOUTH STREET OWNER'S NAME HYANNIS ICE CREAM
ADDRESS: I YARMOUTH TEL: I FAX:
OCCUPANCY TYPE: COMMERCIAL ❑■ EDUCATIONAL ❑ RESIDENTIAL ❑
NEW: ❑ RENOVATION: ■❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑■
FIXUTRES 7 FLOOR—
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BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT
HEATER - _ ___
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DRYER
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FIREPLAC
FRYOLAT
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FURNACE
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GENERA
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GRILLE
LABORATO
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MAKEUP AIR
UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
AUTOMATIC GAS VALVE
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INSURANCE COVERAGE
I have a current liabilily insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES ❑■ NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY N 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
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._ F
PLUMBER/GASFITTER NAME: I LEON E CLARK, JR. LICENSE # 11734-M I SIGNATURE fl,
COMPANY NAME: I TC TYNDALL & CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: I SOUTH DENNIS STATE: FMA I ZIP: 102660 1 FAX: 508-385-9177
TEL: 508-385-8868 1 CELL: 508-367-1451 EMAIL:
MASTER❑ JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION ❑■ #PARTNERSHIP ❑ #0 LLC ❑ #0
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