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MASSACHUS (FORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CRY I Yarmouth (. MA. DATE IoA1//.1. I PERMIT !>/,,-3n
JoesITEAooREss I5 I i best? Ln pw
J OWNERS .E 11l i h f e 5 ict/e+15
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OWNER ADDRESS: I I TEL:I I FAX:1
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YPE OR OCCUPANCY TYPE: COMMERCW.❑ EDUCATIONAL ❑ RESIDENTUL*
CLEARLY NEW:0 RENOVATION:0 REPIACEMENr PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 1 FLOOR-• semi 1 2 3 4 5 8 7 8 9 10 11 12 13 14
SOIER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
ORYER -
FIREPLACE
FRYOLATOR FURNACv
TOR V. :13L' U
GRILLE
LABORATORY COCKS l 0 „1 ? • ''61 ' .S
MAKEUP AIR UNIT
OVEN
POOL HEATER RWM rote,nErn
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
t14VENTED ROOM HEATER
WATER HEATER •
I have a current INSURANCE COVERAGE
knaranee policy or Its subs 1M equivalent which meets 0he
requkenenbdMGL.C�>�r2 f" fES` Nli _
If you have checked YEA,PieIndicate Bre d
hPe coverage by dnaddrng the appropriate boa baba.
LIABILRY INSURANCE POLICY} OTHER TYPE mown, CI Flor [.CT�2 4 SS
OWNER'S INSURANCE WAIVER:I we aware that the licensee gges,Dglny the Instance coverage requhd bytprepter 2`6�tlk/
MessadanNb General Laws,and that my signature an this permit application Kelm Ods requirement.
SIGNATURE OF OWNER OR AGSM CHECK ONE ONLY: OWNER 0 AGENT 0
hereby curtly 0W al of 0a delab and Int ration thaw eubmt ed(or entered)regardkng Ste application as Mae and accurate Ir 0a beet dm
Knowledge and OW al plumbing work and InatebOorne performed under tie peat Sad M Pie appikutlan • with al Perinent
provision of the Maeeedaaete Stab Plumbkng Code and Chapter 142 of to General Laws. Alin
PLu�NM E: Ail M . !' LICENSE:III2J,1 SIGMA I,N p� 8'
COMPMNYNAMEI '�scon dant • Pi/ ithy IAODRES9:lya A094rt //..1 9b<foll
CITY: I L` ynt 'nn-111J5 s I/STATE ( r I aP. 'p.flh7— FAX:( I
TEL:IC1 Pt) q 7"" H I Cat I EMAIL: I
MASTERWJOURNEYMAN❑ LP INSTALLER 0 CORPORATION❑,4 PARTNERSHIP❑t ___LLC❑if