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HomeMy WebLinkAboutBLDG-13-659 v.r+ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •}rev_ 41CITY Yarmouth I, MA. DATE I Gift! / Zef_7 PERMIT# 6�3 'C09 JOBSITE ADDRESS 127 /&86e17f 7J/Zn/E- I OWNER'S NAME TtiPPE/2 I GOWNER ADDRESS: I ITEL I IFAX:I TYPEIr OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ' CLEARLY NEW:0 RENOVATION:©7 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXUTRES 1 FLOOR-. Bsmt 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 OWN POOL HEATER ROOM f 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 1214-.C.1 NO/ ❑ If you have checked LEI,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY 0 BOND 0 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 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 wider the permit Issued for this application will be compliance 'th all ertinl provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBERIGASFTT FER NAME: I /44r9,4c C-ocv p3 I LICENSE it 3/3-E'/ SIG RE �4 COMPANY NAME I Ear/,420) P 4 I ADDRESS:170 /9-4,77^-6- •ZerA/e I CITY: Ile Vm2nrtw, v( ISTATE MI ZIP: I0Z4'73 I FAX I JE" g- I CELL:I I EMAIL: I�,JQURN arf l4 LP INSTALLER 0 CORPORATION.❑#��PARTNERSHIP 0#1 I LLC❑# ��i7�1%J la94t3 ds'o BUILDIyS, sT yJ �) By (f7/!� J�/T