HomeMy WebLinkAboutG-13-162 I•
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c1C .` MASSACHUSETTS UNIFORM APPLICATIpN FOR A PERMIT TO PERFORM GAS FITTING WORK
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t.tr_ , CITY (Yarmouth I, MA. DATE r y— s—/a I PERMIT, 6/3- X42
JOBSITEADDRESS I 79.j item 8 IOWNER'S NAME I 7.3-FSP J
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G OWNER ADDRESS: I Cr/i' 5,4ce ettrn MIL: I I FAx I 1
TYPE
ENIOf OCCUPANCY TYPE L COMMERCIAEDUCATIONAL 0 RESIDENTIAL
CLEARLY NEWer2C.RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
"E
N9 FIXUTRES 1 FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER kC r C "4vL '-°Jr
�'. s 1 V
COOK STOVE
DIRECT VENT HEATER
DRYER SSP - 5 ZO 2
FIREPLACE
FRYOLATOR w.f'e r -
FURNACE -- __
GENERATOR
GRILLE r
LABORATORY COCKS IJ
EOVENMAKEUP AIR UNIT
(NT
POOL HEATER I
ROOM/SPACE HEATER ' /l
(l)
ROOF TOP UNIT �f /
Ilk
TEST
UNIT HEATER —
UNVENTED ROOM HEATER
WATER HEATER
COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 VESA NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY.i OTHER TYPE INDEMNITY 0 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 CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that ail 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: 11S.Ant t I t7\. �i C-ILR I LICENSE# m qa'c k( SIGNATURE�'
COMPANY NAME: 1411 Pei At, ({'rt 7 C IADDRESS:I /I ClryrlP ,cf I
Com: I w- ft c ONOkA t1& ISTATE: Mil ZIP:I026. y I FAX I I
TEL:I'774f-1170-6'7b"I I CELL:I ( EMAIL• I
MASTER%JOURNEYMAN 0 LP INSTALLER 0 CORPORATIONt' # 3:139 PARTNERSHIP 0#1 (LLC❑#
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