HomeMy WebLinkAboutG-12-642 \ _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`: ii= CITY (Yarmouth +
Ml� r DATE Lilly/LI PERMITIN IZ- CyZ
D z JOBSITEADDRESS (6g ( J vi y(mw r j OWNERS NAME I rl ask 57,15 evet I
o q OWNER ADDRESS: I 'fl Wi-„9/mw (9.3-Q7 Rat I TEL (502) (45-&7WIFAX:I
(�' P ,R OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
LLI J TY.E4LY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
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W s` O UltE.p7 FLOOR- Bamt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
_B 5el..
BOOSTa d
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
QYe5yklrt bey to
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES/Kik) 0
If you have checked LES,please indicate the type of cov• • by checking the appropriate box below.
LIABIUTY INSURANCE POLICY a 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 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 application will be mpllance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTERNAME I Air..s< SQ g q I UCENSE#I UJ/ SIGNATURE
COMPANY NAME: I h2-coq Armq• 1rAr/P6,/ IADDRESS:I YJ RV9gr� tvi t„21 1
CMY: 1 14 Pt vt� r•5 O I STATE: r, ZIP: I Or)hd/ I FAX: I
TEL:r('77/N ) Ea7-Ym rr/ I CELL:I I EMAIL: I
MASTER'JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0#IPARTNERSHIP 0#II LLC 0#O!
ROUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES =
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT
PLAN REVIEW NOTES
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