HomeMy WebLinkAboutG-13-556 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
pi CITY Yarmouth I I PERMIT# 611-33&
• � I, MA. DATE /2—!b 'lZ
JCBSITE ADDRESS Ie 474 I OWNER'S NAME I 7/ck glA 0
GOWNER ADDRESS: I 1.0• C// "J1 . I TEL I I FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL
P0 RERESIDENTIALRINT Or
CLEARLY NEW❑ RENOVATION:0 --REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO9Z0
FIXUTRES 7 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
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
• INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.1
tpE
If you have checked KS,please indicate the type of coverage by checkingthe
appropriate box below.
LIABILITY INSURANCE POLICY r OTHER TYPE INDEMNITY 0 BODEC 10 2012
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Ch pter 14FNI4GGQ y�
•
Massachusetts General Laws,and that my signature on this permit application waives this requirement By
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:nd accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permk Issued for this .•• - _ . Ih .I Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. IWi ,
PLUMBERIGASFrT•rERNAME:1 IS06 01t°lc—rU LICENSE# /06D � RE-
COMPANY _ '�`'V
NAME:191 bcr_s 1 �1� t( �,,y , ..y IADDRESS:I /62
CITY: IpA�J frt. m`(( ISTATE Usil LP:I (92-64"0--I FAX
TEL I `!off' j?J-f{$Si JCELL:(.J*535-&ct I EMAIL: I /14 IbCf3 I.Gcgr—. . Cv�
MASTERRNEYMAN 0 LP INSTALLER 0 CORPORATION 0#1 (PARTNERSHIP 0#1I LLC❑#