HomeMy WebLinkAboutG-13-605 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
i1/4e. CITY Yarmouth MA. DATE 1 /.2/ate//jam- I PERMIT# Zig-6r
JOBSITEADDRESS I a Y9 cSjd %, Ave_ 1 OWNER'S NAME s- /vtbf. -aims y 1
GOWNER ADDRESS: I • I TEL sgs 6 f 3i I mkt 1 I
TYPE OR OCCUPANCY TYPE: COMMERCIAL E,/ CATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑
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
FRYOLATOR
FURNACE I
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 NO ❑—
If you have checked YE$,please indicate the type of coverag ch thea } '" 1° .'�g '' t2 1
�9appropriate box below. r#f�/
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LIABILITY INSURANCE POUCY OTHER TYPE INDEMNITY 0 BO'D ❑'OEC 2 8 2012 t
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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 ran this requirement. /....p .-.`
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT 0
hereby certify that all of the details and InfomratIon I have submitted(or entered)regarding this application are true and ... .;: �. , : •:.t of.
Knowledge and that all plumbing work and Installations performed under the permit Issued for this a.n tion II i .-it , : .;I all P:-.- t
provision of the Massachusetts State Plumbing Code and Chapter 1 2 of the General Laws.
PLUMBFR/GASFITTERNAME: I DEi�jlg •Shol�( I LICENSE#If,fl II I 10'(TUR
COMPANY NAME:I 4 jf 7 n(-Yet- c441 evil/lo7 J ADDRESS:I 9g7 IZ/ &b 1
CITY: I ifti,,/i ficOL I STATE .ZIP:1626 'IAI FAX I 1
TEL I:SZI°U 2M - Yy I CELL:I I EMAIL I • I
MASTER JOURNEYMAN 0 .LP INSTALLER 0 CORPORATION 0 it PARTNERSHIP 0#II LLC 0#0