HomeMy WebLinkAboutG-12-733 .5:1.` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ct f= CITY I Yarmouth I. MA. DATE I a. / — /2 I PERMIT#C 0-755
JOBSITEADDRESS I y9 Pipe-A.. w(- Si- I OWNER'S NAME I �Jj'(I rye. 1
OWNER ADDRESS: I I TEL: I I FAX I I
TFREW
YPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
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
RECEIVED
DIRECT VENT HEATER
DRYER
FIREPLACE —
FRYOLATOR
ii 22 ?012
FURNACE BU LDIN �Fo�,RTM�
GENERATOR By: / T
GRILLE
LABORATORY COCKS f ((y L.tOVEN
Elkr g S
MAKEUP AIR UNIT L I
• POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
NokSi (V. p:v - x
I have a current liability insurance policy or its substantial equivalent INSURANCE
Cwhich meets the requirements of MGL.Ch.142 YES 0 NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY 0 BOND ❑
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 codify that aft 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 all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME I')p.v 1 VC-tit-5 I LICENSE firozw4 SIGNATURE
•
COMPANY NAME I ePlekj 1 5 (jI(aNt id rtera- I ADDRESS:13 -51,n(1-6- ori I
CITY: I t-t-ctrw;C_I-t I STATE bal ZIP: 1 Od.&, 4 '
I FAX: ( 1
TEL I G738-1•R-2.-1S3 p yY I CELL:1774-53c4$ .EMAIL: I
MASTER 0 JOURNEYMA!A LP INSTALLER 0 CORPORATION 0#1 (PARTNERSHIP 1:1#1 (LLC 0#
ROUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
THIS APPLICATION SERVES AS THE PERMIT Ye 0
6 - 4 - ( z- ?V a FEE: $ PERMIT 1
PLAN REVIEW NOTES