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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-ing-y CITY Yarmouth MA DATE 10/1/2018 PERMIT# (T-ff-X/? 3
JOBSITE ADDRESS 8 Captain Dore Road OWNER'S NAME Diane Russ
G OWNER ADDRESS Same TELj508-398-2932 FAX
TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES[] NOD
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER 5 °4-,Cs'1;-t I1 d, tr —,, 1 rI. .. --a,"' . . _ . .f-
CONVERSION BURNER ti is is oi os RI f s_ �-- l_ . - ---. -----
COOK STOVE 1 N, y !
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DIRECT VENT HEATER � h 1. �i r =' •
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DRYER —
FIREPLACE 4 i
FRYOLATOR - 'Mr'
`p: p^ ¢I ,� t
FURNACE �_.. — '
GENERATOR
GRILLE 1 Ix.._.- {I ..... I 1i=-= 1 ; a': r I
INFRARED HEATER 1 11 :i 11 t :l it .1
LABORATORY COCKS v' V *, f _ t,
MAKEUP AIR UNIT I.I
'- : • / m ml
OVEN a i. N w r UC '4 oi&
POOL HEATER G -.. r f t I
ROOM/SPACE HEATER pf II ! p nl .'.. .. } ! _!
ROOF TOP UNIT 1, II
TEST
UNIT HEATER L t1 f. �, � —tl t q
UNVENTED ROOM HEATER 1
WATER HEATER 9 _ g'h
OTHER
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D 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 (D
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 lance with all Pertinent prow4jon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J\
PLUMBER-GASFITTER NAME David P Lyons LICENSE# 113081 SIGNATURE
MPQ MGF® JP(3 JGF® LPGI® CORPORATIOND# 2124C PARTNERSHIP 0# LLC D#
COMPANY NAME:Lyons Plumbing and Heating INC ADDRESS X632 Cambridge Street
CITY Worcester STATE MA ZIP 01610 TEL 508-845-1924 J
FAX CELL 508-868-3761 EMAIL lyonsph@verizon.net
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