HomeMy WebLinkAboutG-12-229 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I Yarmouth
I, MA DATE I /O// // I PERMIT/0_12_12-
JOBSITE ADDRESS I 4/ GG/c,f GN I OWNER'S NAMEI Are e, tAr/ *LS J
G OWNER ADDRESS: I
I TELTYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ �Dg RESIDENTIAL r-�
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:DZ.'
PLANS SUBMITTED: YES 0 NO
FIXUTRES 1 FLOOR-. Bsmt 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOILER
BOOSTER _
CONVERSION BURNER K C . IVc D
COOK STOVE
DIRECT VENT HEATER i T _
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
• INSURANCE COVERAGE
I have a current!lability Insurance policy or Its substantial equivalent which meets the
requirements of MGL Ch.142 YES �0
If you have checked lis please indicate the type of coverage by checking the app ate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee Amami,the Insurance
coverage required
Massachusetb General Laws,and that my signature on this permit application! this requirement. by Chapter 142 of the
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that al of the details and Information I have submitted(or entered)regarding this application are hue and accurate to the best of my
Knowledge and that all plumbkg work and irotallapone performed under the permit Issued for this application will be In comp withal ent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws,01c/j 3
PLUMBS R/GASFITTER NAME I yr) 0 IA,at/I( I LICENSE#I .O,6L`3I SIGNATURE
COMPANY NAME:I era en 0 "a.vuel/ P fhe IADDRESS:I NO- b'oX 30//
CM(: I IAJAC u0 /-/^ STATE
I � Z1P.� 4d��Ui I FAX: !
TEL: 15 SyK 0rc kyl cat.:15-02-5-b�/ 7emt:• I
MASTER 0 JOURNEYMAN26 /0) 51
LP INSTALLER 0 CORPORATION 0# #PARTNERSHIP 0#EJ LLC 0 lI
oL c
y I , 0 et, BiLOW FOR OFFICE USE ONLY
FINAL INSPEC�ON NOTES
�,1y�' Yes No
I— / J______ TION SERVEt THE PERMIT ❑ ❑
FEE: S PERMIT t
of NREVIEWNOTES