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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
inkit 15"- CITY I Yarmouth 1. MA. DATE IlEnglenalli PERMIT*a-12_-607‘
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JOBSITE ADDRESS 11 h e ?baler lig 037 R b.31.6 I OWNER'S NAME I r(11q •( rif tt I I� R
U4`• • , o, • ■ RESIDENTIAL ■
PLANS SUBMITTED: YES 0 NO 0
W1 1' ■ a • ■ a. o �i
ES 1 FLOOR-•
12 13 14
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES rYCI 0
If you have checked yrj,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY Oi< 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 waiv@y this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that al of the details and Information I have submitted(or entered)regarding this applicator are true and .,.. c to to .: t of my
Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will .�,, . with al Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `�1
PLUMBER/GASFITTEnR NAME: I A i C& tscif3ct I LICENSE#f If4I SIGNATURE n'
COMPANY NAME:Ig rq q iPn t• Off A// I ADDRESS:11J It O 94r y LI, 5 tr d( j
CITY: (147 q A-1 I s J STATE Ea ZIP: W.enIJ#1 FAX: I
TELI CELL:I I EMAIL: I
MASTER JOURNEYMAN 0 LP INSTALLER❑ CORPORATION❑#CIPARTNERSHIP 0#II LLC 04
ROUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: $ PERMIT S
ELAN REVIEW NOTES
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