HomeMy WebLinkAboutG-13-686 5-01
_� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
it CITY IYarmouth I, MA. DATE I /—,zC-I 3 I PERMIT# 614-6P6
GJOBSITEADDRESS i a ecu-.�r lL) RQ OWNER'S NAME ( k„c � I
OWNER ADDRESS: S-1i.7,e(b,ack k-.Y. 6&rdr�(/.q (� �f IFAX:I I
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDU/CATIONAL ❑ l RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:'❑ REPLACEMENT:pia PLANS SUBMITTED: YES 0 NO :9
FIXUTRES 7 FLOOR-. Berm 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
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
•
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO 0
U you have checked yam,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not hay@ the Insurance coverage required by Chapter 142 of the
( �
cchusetts G al Laws,and that my signature on this permit application waives this requirement.
�tCHECK ONE ONLY: OWNER AGENT ❑
SI ATURE OF OWNER 0 AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate b 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. _
411
PLUMBERWGASFITTER NAME -I Ki /Y e R4V6SO/r j LICENSE# l///2 'SIGNATURE Y N
COMPANY NAME:I 1(54/ '5 Pa-N J ADDRESS:I 4/ LAURA KF E/✓/%/4 net
CITY: I ,4 G vs-iv/YET I STATE ITJ ZIP: I Lv .L7 II I rr I
TEL ro y7o O 3.r/ I CELL I 4' ^{5"/ /2J-4I EMAIL• l l f
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MASTERI2' JOURNEYMAN❑ LPINSTALLER❑ CORPORATION❑# PARTNERSHIP❑#I LLII320 —1
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