HomeMy WebLinkAboutG-13-700 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
t- CITY I Yarmouth
I,� MA. DATE ( 102 S-- l3 I PERMIT# 6/9-70
JCBSITEADDRESS I L/t/ eld PG'. I OWNER'S NAME (acm I Nelson
GOWNER ADDRESS: I L/I-( Ra I TEL I I FAX:I
TPT
YPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL(Y
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 1 FLOOR-• Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE F
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
I have a current liability insurance policyor its substantial INSURANCE COVERAGE �/'
equivalent which meets the requirements of MGL Ch.142 YES LTJ"NO 0
If you have checked yg ,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER: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 applicationiwa ves 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 under the permit Issued for this application will be in compliance with al Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f
PLUMBER/GASFITTERNAME I 7"eF\-eN' Rjctice0 ILICENSE# IMO SIe 'f
COMPANY NAME:I1446;0d- PIvNhb"S t -c. IADDRESS:1 '7 5 . /J7giN S'd• •
C : a , yr STATE Min ZIP: I 02230
r n raaysr�U I FAX: I,5913gG6 3,2oy l
: ! X ' ,v' CELL:IPic BVL' '551 EMNL Ipo6 PIw.1b;1 ;tie t VcsiZatil. "—et I
' I1
. 1 R 02.18 Fi'Qif! ■ • INSTALLER❑ CORPORATION❑# 3/6 LI PARTNERSHIP 0# u.c❑#0
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