HomeMy WebLinkAboutG-13-025 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'•'=t•'1= L CITY Yarmouth I, MA. DATE � �/ f PERMIT
rr fl JOSSITE ADDRESS$7 Ej 5 S4 //w/, J OWNER'S NAM(/tY/ ' .
<T OWNER ADDRESS: VoE6totl/4!/ /1// �I. 3- 5�D - FAX
— TYPE OR 1 ?gl�
1 OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,®
LEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑
PLANS SUBMITTED: YES 0 NO❑
IXUTRES 1 FLOOR-. Bsmt 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BOILER I
��_- 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
COVERAGE
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I have a current liability insurance policy or its substantial equivalentOwhich meets the requirements of MGL.Ch.142 YES 0 NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 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 detals and information I have submitted(or entered)regarding this application are true and r rate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit Issued for this appl•.tion `A w' p .,
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' P with all Pertinent
PLUMBER/GASF1TTERNAME I/11/P-a £6P/AJg. I LICENSE SIGNA RE - -
COMPANY NAME: IA/Zee-SP/11;E /YA/ I ADDRESS:I j
CITY: I et. 41/lit{Jt/-i, 26 I STATE fl ZIP: IO2-6 / j I FAX: I
T Og I CELL:.aeo Ifdyt UL•
MASTER JOURNEYMAN 0 LP INSTALLER 0 CORPORATION #I (PARTNERSHIP 0#1::=1 LLC❑#I
ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
7_ l7 _ / 7, Ggs � Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ D
FEE: S PERMIT I
PLAN REVIEW NOTES
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