HomeMy WebLinkAboutG-13-077 I. 1W! 6/15
fI. , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-�tr_— CITY Yarmouth p 2 �1
� �� MA DATE I �I3///.Z I PERMIT I J ��/
JOBSITEADDRESS I $7 Uturtig it car , OWNER'S NAME I fl'td(al,5,1
G OWNER ADDRESS: I I TEL ( CO—Xf(-C9c01FAx:I
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 7 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
G
GENERATOR '
GRILLE
LABORATORY COCKS , ` ° •
' lI
u
MAKEUP AIR UNIT
OVEN
nut "'4 •FPT
POOL HEATERL J
ROOM/SPACE HEATER v
ROOF TOP UNIT tar
TEST —
UNIT HEATER •
UNVENTED ROOM HEATER —
WATER HEATER
a 45 12t-P -A/(-) ?C
COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES [alp 0
If you have checked Yg,please indicate the type of coverag 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 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 a and accurate to '/ best of my
•
Knowledge and that all plumbing work and Installations performed under the permit Issued for this application II be In co . .n-.: •I all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: IS ,..I F 0 Z./MtI LICENSE#tun S G TORE '/�
/
COMPANY NAME I41'a1Q�E Vt_ 41(._ / I ADDRESS:I `.J FecRy44 a I
CITY: I 'i'I-•y(1ft on+ I STATE FAM ZIP: 1 09.16O ( FAX: I I
TEL' I r"757— 4/E0f) j CELL•) I EMAIL I IC4h/050tC/4t2y t i) A-oL Loaf I
MASTER 0 JOURNEYMAN' LP INSTALLER 0 CORPORATION 0#1 'PARTNERSHIP 0#LJ LLC 0#1 1
• ROUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
&f 679 dfc 1-0e/f Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT 1
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PLAN REVIEW NOTES
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