HomeMy WebLinkAboutG-12-501 sZ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'=n -• CIN I Yarmouth LAJ P 5-7-1, MA. DATE 7. / Z PERMIT#y-i 2- 5(y t
JOBSITE ADDRESS I S /c-(je d'La*-P c n OWNER'S NAME(i+L ,51-4/7175/e-4--51
G OWNER ADDRESS: ITE: I IFAX:I I
TYPPRINT
CLEARLY
OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL,
CLEARLY NEW❑ RENOVATION:0 REPLACEMENT:a PLANS SUBMITTED: YES 0 NO I1
FIXUTRES 1 FLOOR-. Bsmt 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOILER /
BOOSTER
CONVERSION BURNER R ' CCI +
COOK STOVE
DIRECT VENT HEATER 74
DRYER 04 i
FIREPLACE =N( c
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 liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES E NO 0
If you have checked Ya please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUCY E OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havq the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application walvel this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that al of the detals and Infomhation I have submitted(or entered)regard . this application are true and accurate to the best of my
Knowledge and that al plumbing work and installations performed under the permit Ism... i. I , .. will be In compliance withal Pertinent
provision of the Massachusetts Stats Plumbing Code and Chapter 142 of the ^ Lan oz
PLUMBER/GASFTfTERIVAME M,( v •
R r. 1 LICENSE#UiZ / SIGNATU ,
COMPANY NAME:I i l4 r,40 /77L lj JADDRESS:IZS'/5ci---c0,. 4-c,-.2--L_ o-RI
Cm: I w_ `fr r e,,, ri,A-Lr I STATE al ZIP:I o 7 /a 7 3 I FAX: I I
TEL I T-71 fr 7 7 9 w194 I CELL:Vizi Vo 9,z2-1 EMAIL I S r1 nl c--e/�1 a n h-11.0 4 r, /yt,q r r • ( U..._--% I
MASTER 0 JOURNEYMAN[ LP INSTALLER 0 CORPORATION #1 (PARTNERSHIP 0# LLC 0#0
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