HomeMy WebLinkAboutG-12-479 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Arks' CITY IYarnouth I. MA DATE I Th a- /a PERMIT#61!2-q79'
JOBSITE ADDRESS I y 9- t; I Prosftc t=s4- I OWNER'S NAME I b W /jo / /- I
G OWNER ADDRESS: I TEL' I sob-333-C077IFAXI
TYPE O'R OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
CLEARLY NEW 0 RENOVATION:0 REPLACEMENT:a PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 1 FLOOR-, Bean 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
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER !
WATER HEATER
INSURANCE COVERAGE
I have a current!lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.14! RfscgiE0,12 E D
If you have checked u,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY 0 9ofO Si
FEB 0 2 2011 11
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chip �4 bith lig PA M rd
Massachusetts General Laws,and that my signature on this permit application Rahg this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby cstify that al of the detate and Information I have submitted(or entered)regarding tib appkation are true and accurate to the pest of my
Knowledge and that all plumbing work and Instaliadona performed under the permit issued for this application will be in compliance with all Pertinent
proHsion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBEWGASFITTER NAME: I nitre w I3rz tnson I LICENSE#1&MP/ I SI a
COMPANY NAME: AYtdiew Ige244san P/cmbmf +Niehn1 I ADDRESS:I x6"aAhtst'
CfTY: I Cast- 6r:i9t„,+0E ISTATE an ZIP: I d2-3
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TEL I •-•1-0(‘-9`g-76 s'a I CELL:I I mat I 1
MASTER 0 JOURNEYMAN :P LP INSTALLER 0 CORPORATION.0#��PARTNERSHIP 0 If LLC❑#
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