HomeMy WebLinkAboutG-13-886 tea-44;0443
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING� WORK
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CITY I Yarmouth I ,3-c)r9 Az I PERM'6/3 8.80
I� Ma DATE .
JOBSITE ADDRESS 1A-9 art
1WerdhT 22d I OWNER'S NAME I 1,0h/in `tjn ybekS I
OWNER ADDRESS: I I TEL Vo8-3la9-,s261I FAXI
TPRINr
YPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL In--
CLEARLY NEW 0 RENOVATION:0 REPLACEMENT:[Gy PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 7 FLOOR-, Bend 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 /
KC&IED
I hav9'ararient liability insurance policyor Its substantial INSURANCE COVERAGE
equivalent which meets the requirements of MGL Ch.142 YES 0 N
If you have checked Las please indicate the type of coverage by checking the appropriate box below.
M
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND - �+
❑ a
OWNER'S INSURANCE WAIVER:I am aware that the licensee goes not havg the Insurance required byco c
• : Laws • . ,1, signature on this requirement.
Chapter 142 of the E' N
�� - Pelt application kr this reQukemerM t-s cc �v
NATUR OFOWN1- ,- y
Ls? Erz
CHECK ONE ONLY: OWNER a AG NT'd
hereby certify that all of the details and information I have submitted(or entered)regarding MS application are true and aavrale to the beat of my
Knowledge and that all plumbing work and installations performed under the permit Issued for this appi gpn will be in compliance with at Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �
PLUMBERIGASFITTER NAME 112eL ' .. C„ I LICENSE# / SIGNATURE R Srtidal — A
COMPANY NAME u g I ADDRESS:I/.•2 1.1.4.4.tet n or$y017 ,vU
CfTY: I r „�C _ /��t I STATE: a 1. ZIP:I / /e 7,5— I FAX: I I
TEL' I 07-37 c tin/ I CELL I I EMAIL I
MASTER 0 JOURNEYMAN Q-IP INSTALLER 0 CORPORATION 0#I!PARTNERSHIP 0#( LLC❑#
BELOW FOR OFFICE USE ONLY B,NAL INSPECTION NOTES
ROUGH GAS INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT If
?LAN REVIEW NOTES
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