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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY IYarmouth I, MA. DATE I /—/6-/3 I PERMIT# b/-4 Orr
JCBSITEADDRESS I/3nQ /J„j.r, 67' Yaamoith foh271 OWNER'S NAME Imr•lie 60Ane ?
GOWNER ADDRESS: I ITEL: I IFAX:I
TYPE OCCUPANCY TYPE COMMERCIAL 0 ED CATIONAL 0 RESIDENTIAL
CLEARLY RENOVATION: REPLACEMENT:
PLANS SUBMITTED: YES 0 NO
FIXUTRES 7 FLOOR- Britt 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOILER as,--
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE •
FRYOLATOR r k)
FURNACE �
GENERATOR U MN 12 70 3
GRILLE
LABORATORY COCKS GUILIN GCEPT
MAKEUP AIR UNIT _Py
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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INSURANCE
have a current liability Insurance policy or its substantial equivalent which COVERAGE he requirements of MGL Ch.142 YESth/NO 0
If you have checked YEl please indicate the type of coverage y checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havq the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waiver this requirement
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
Knowand that
allt of
the details and Information I have submifted(or entered)regarding this application are true and accurate to the best of my
plumbing work and Installations performed under the permit Issued for this application will be in comp i. ce with all P nent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME flicbbtl V f -n tit i± UCENSE#1 U7905 I SIGMA iR/ 'I
COMPANY NAMEIR•1j.4r4 P frd��J Sr IADDRESS:I Po Bo5( y73
CITY: I Wr•"Cv c4-.er- I STATE PA9 ZIP: I 0 2 C3! I FAX:
TEL:15128 397' 9S W 5 I CELL•I Sol 9 SIf /Y2I' MAIL' I •
MASTER[JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0#r �PARTNERSHIP 0#I LLC 0#CI
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