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G-18-2755 .'-• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [YARMOUTH MA DATE November 07, : PERMIT# BLDG-18-002755 JOBSITE ADDRESS 32 GORDON LN OWNER'S NAME MELO CASSIO R G OWNER ADDRESS 32 GORDON LN YARMOUTH PORT MA 02675 TEL[ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOQ 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 1 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 1 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 Q NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER OF 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 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 Alex Braga LICENSE# 15668 SIGNATURE MPQ MGF❑ JPO JGF❑ LPG(❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ALEX B BRAGA ADDRESS 2 MOUNTWOOD RD, CITY MARSTONS MLS STATE MA ZIP 026482111 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El ❑ FEE:$ PERMIT# PLAN REVIEW NOTES ROVI /9-9 AZ- 6 d/° fb°f� Ha/n O'er