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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I Yarmouth
I. MA DATE 18''13— /p- I PERMIT#J*1 & J er�
JOBSITE ADDRESS I c'a Qefff/1t k/ 4O. J OWNER'S NAME I4L/ir,Kp 60/t4- p 'O
EDA
G OWNER ADDRESS: I I TEL I I FAX:( i
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ai
PRINT
CLEARLY NEW:B/RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 9-
FIXUTRES 1 FLOOR-- Beni 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE /
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER — —
ROOF TOP UNIT s r h
TEST s �` I
UNIT HEATER h
UNVENTED ROOM HEATER h f ',i� cu u h
WATER HEATER /Jn cr�/y�2, �h
711
I have a current liability insurance policy or its substantial Iequivalent Cwh�m�ay
t you have checked requirements of MGL Ch.142 YES IE-NO 0
,please indicate the type of coverage by checking the appropriate box below.
UABIUTY INSURANCE POUCY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massacarsetts General Laws,and that my signature on this permit application waived this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
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 wi be in compliance with at Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITrERNAME: I/t 44140 Q4itp7gce- ILICENSENI/17eaI SI TUBE
COMPANY NAME:I g,Q/er--gL/—ey-loz IADDRESS:I? a raf>4.vrjo4k
CITY: I /filet s (STATE ZIP: 102-C VS— FAx I
TEL I I CELL:Jfl 37.26-7I EMAIL 14447-06647°41, Q Q7
MASTER 0 JOURNEYMAN 0 LP INSTALLER 0 CORPORATION❑#r_1PARTNERSHIP 0 pr �LLC❑a
l3O 4/2&
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ROUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTIONO ES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0• FEE: $ �� '
r<IP 1 A 7,
PERMIT i
PLAN REVIEW NOTES Otr- e—i