HomeMy WebLinkAboutG-12-314 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK
CITY I Yarmouth
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I, MA. DATE
MffnleThluPERMIT#G1 _
JOBSITE ADDRESS I:.5-6 Cetty, S7L- 1 OWNERS NAME I Way Ca r.e
lJ OWNER ADDRESS: I L-c4- W r r vu,* I TEL I Cog 9 3-337I FAX I
Tp PRE TR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ 0 RESIDENTIAL 0
PLANS SUBMITTED: YES❑ NO❑
FIXUTRES 1 FLOOR-0 1 2 3 4
BOILER - Ba5 8 7 8 9 10 11 12 13 14
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORYCOCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM ISPACE HEATER
ROOF TOP UNIT
TEST.
UNITHEATER -
UNVENTED ROOM HEATER
WATER HEATER
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I have a current liability Insurance policy or Its substantial equivalent COVERAGE
I} to I 1 L I
H you have checked YES,please Indicate the rements� Ch�42 YF ¢Q fW
type of by checking the appropriate tax below. Iu1I 11u1I Nov 2_ <n i L.. CD
LIABILITY INSURANCE POUCY jig OTHER TYPE INDEMNITYJ
OWNER'S INSURANCE WAIVER I am aware that the licenseeAoas a
see 0 BOND„❑, =u, 1L, r J
Massachusetts General Laws,and that my signature on this permit application
haw s coverage amu` fiy>rhaptlYT42ottihe
px�k 1Y83 this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT 0
hereby certify that al 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 al Pertinent
provision of the Massachusetts State Plumbing Cade and Chapter 142 of the General Laws.
PLUMBER/GASFTTTER NAME I K ca'jL €4eb.44., (LICENSE#® SIGNATURE
COMPANY NAME: I WbMpty'4 ;a,V C-- IADDRESS:I 3 Y 49(ts+2 t< '�,s _
RYI
C : 11st
yse n2FwpJ�G` I STATE ar: ZIP: I I FAX I
TEL: ISMS- SS- (rSGQ 10ELL•I I MAIL: I
MASTER rt JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑#
inini PARTNERSHIP 0#1=LLC❑#r_�
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PaugugaM2W:132thCaM IFISSWS makilimaliziNIMEI
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FEE: $__________ PERMIT 1----- -----------
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