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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY Yarmouth I, MA DATE I /o/Za-/,i IPERMIT#G 12 - Qqg
JOBSITE ADDRESS VO g B2d4'J FflVM /2d boat OWNER'SNAMEI ill Con 4 bS
GOWNER ADDRESS: I ITEL: I I FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL Er EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:D RENOVATION:0 REPLACEMENT:0
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 c t y 1
POOL HEATER � h
ROOF TOP UNIT ` \Zn\, l 1'
TEST t+ROOM SPACE HEATER
on
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UNIT HEATER
UNVENTED ROOM HEATER _ - _
WATER HEATER
INSURANCE•
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 315 0
If you have checked yu,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY eOTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:lam 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 waive%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 MI be In compliance with at Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws,
PLUMBER/GASFIITERNAME: IA1/Me) /}.rjPabih �LICENSE#I9-'4aLI SIGMA E
COMPANY NAME:1,4 PO C I O C A-o .F .tea Zt I ADDRESS:b_) ch4m'A A ige-7 I
cm: I Pii//-etzccr� JSTATE 2Sa nP:I/VI' z--( I FAX: I
TEL it/-J/1/47- 3 Sill I CELL:I J EMAIL: I I
MASTER JOURNEYMAN 0 LP INSTALLER 0 CORPORATIONq o PARTNERSHIP 0#I LLC❑#
��,., wenclTlAN NOTES
BELOW FOR OFFICE USE ONLY
ROUGH CAS INSPECTION NOTES .vecc- b4 �✓ G n
O ` Yes o
THIS APPLICATION SERVES AS THE PERMIT ❑
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FEE: S PERMIT
PLAN REVIEW NOTES
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