HomeMy WebLinkAboutG-13-629 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1-n= ` CITY Yarmouth , Mk DATE 16//OAF// 3 I PERMIT# vI3'4.919
JOBSITE ADDRESS I SS I-I;$/,wJ St I OWNERS NAME Tow .1QCry' I
GOWNER ADDRESS: I SS S In I e*a cJ Sr I TEL: lit -)SC -)03?I FAX:?
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Qi
PRINT
CLEARLY NEW:0 RENOVATION:D-REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO rU'
FIXUTRES 1 FLOOR-. Bamt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ✓
BOOSTER
CONVERSION BURNER
COOK STOVE t%
DIRECT VENT HEATER •
DRYER
FIREPLACE it'
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 requlrem 1.f hF14t Y . 11111 I r ■
If you have checked Y,j,please indicate the type of coverage by checking the appropriate tax ,= i I J a 2012,• ui,
LIABILITY INSURANCE POUCY 0 OTHER TYPE INDEMNITY ■ DOWD,'
OULUN
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance cov ,:.uIr „ ,.: _ - +•
Massachus• 'e en. 4.ws,and that my signature on this permit application waives this require -
/ CHECK ONE ONLY: OWNER AGENT 0
SIGNA RE OF OW • 0 AGR ENT
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: I L iA-r, I%/(y I LICENSE# r SiGNATU E
COMPANY NAME: I L544— u.r,10n3 IADDRESS:( cs...55/eve S`r I
CITY: I (r - 'iia- I STATE Fin ZIP: 0.2.( 3( FAX: N/m-
TEL• V(o( ) S2_3- 3-7-RC. ICELL:kr,042.01853oI EMAIL' I ,/.4 •
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MASTER Er—JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0 it LLC❑#Q