HomeMy WebLinkAboutG-13-169 V K
tr- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t>uf CITY Yarmouth I MA DATE ( 9 - t 3- p__ I PERMIT#
JOBSITEADDRESS I 4 4 I OWNER'S NAME p4EkJC12- Fic,r.l .3 I
GOWNER ADDRESS: I 5 4 01 C I TEL: I y i .qq,' I FAX:(
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YPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAb
CLEARLY NEW:0 RENOVATION:0 REPLACEMENTS_ PLANS SUBMITTED: YES 0 NO 0
FIXUTRES 1 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 F V t D
FRYOLATOR
FURNACE 1\111 -S-
GENERATOR 1 S11) .0
GRILLE L
12
LABORATORY COCKS mNy
MAKEUP AIR UNIT —
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER .<
•I have a current liability Insurance policyorits substantial INSURANCE COVERAGE
equivalent which meets the requirements of MGL Ch.142 YE5'0 ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICI _ 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 true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit Issued for this ap ' will be mpllance with al Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME I \ VV e fh J UCENSE# .-q SIGNATURE
COMPANYNAMEPq,l C3 L, Vtvt,-/‘6,hc-✓ IADDRESS:I� `-'51.4x
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CITY: I t w10ti ISTATE: bail ZIP: I CJ i`(rI FAX: I
TEL (51)P.—V?z 0•°,3-/J CELL:177y'S3 f EMAIL 17d a/S e✓iarn y'q 6) Tca
MASTER 0 JOURNEYMS_a.PINSTALLER 0 CORPORATION 0# PARTNERSHIP 0#1 jLLC❑#0
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