HomeMy WebLinkAboutG-13-416 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I Yarmouth I, MA. DATE I ////il/g I PERMIT# q13 - `116
JOBSITE ADDRESS 19, yE/i J Rlt v C N I OWNERS NAME I JBL FARECE/ I
G OWNER ADDRESS: I I TEL• I 'Si- i`9 R43?$I FAX:I
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ 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
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVP.
WATER HEAROOM HEATER e�Tt4) p/ l�
I have a current liability insurance policyor its substantial TER
• INSURANCE COVERAGE
equivalent which meets the requirements of MGL ° 14 lEE
iii U
IO
If you have checked y please indicate the type of coverage by checking the appropriate box below. L Lq U
LIABILITY INSURANCE POLICY Ei OTHER TYPE INDEMNITY 0 :r ND/EY 8 2012
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required tpapielJliabrtRiPT
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 ap of the details and information I have submitted(or entered)regarding this application are and accurate to the-b-- of my
Knowledge and that all plumbing work and Installations performed under the permit issued for this application in compliance /: Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME I.5C4M F O'L6442 y I UCENSE#rJ95 7I SIG RE
COMPANY NAME IAwrfai4c /I. .41 &1
� (ADDRESS:I ct 6Sj/4/./
YJ�
CITY: I f I {'k0 I STATE MI ZIP:I O02 36O I y FAX: I
TEL I SCIS -°759 ^ 41600 I aI I EMAIL' I I.<44-(D SQ7�'4I<Y 0) /oL•COU4
MASTER 0 JOURNEYMAN, LP INSTALLER 0 CORPORATION 0 4 jPARTNERSHIP 0#L1 LLC❑it