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HomeMy WebLinkAboutG-12-269 13k _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK n CRY Yarrouth / / I PERMIT#612_ Peo I, Ma DATE II '� 11 GJOBSITEADDRESSI , enrcd;nnr• lam. 1OWNER'SNAMEIM;r�ea.Ic 8e OWNERADDRESS: I Cj , Yorm nJ}/ I TEL:raga)3a0-5aa 5 I FAX I 1 TYPE OR - OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL PRINT1 0 RESIDENTIAL CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:€ PLANS SUBMITTED: YES 0 NO❑ FIXUTRES 1 FLOOR-0 Bacot 1 2 3 4 5 8 7 8 9 10 11 12 13_ 14 BOILER BOOSTER -� r- Rn .-• q a. I"1 CONVERSION BURNER - �{ COOK STOVE rt N(V 0l i DIRECT VENT HEATER DRYER ! FIREPLACE fl.1 FRYOLATOR FURNACE 0 GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER L7ctsp:p rq lacca U ERAGE I have a current liability insurance policy or its substantial IequuivaCwhE�meets the requirements of MGL.Ch.142 YES aNO ❑ If you have checked yes,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the Ikensee does nW have the Insurance coverage mired 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 hue and accurate {. the best of my Knowledge and that all plumbing work and installations performed under the pernk Issued for this application will be ••mplian': withal Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFER NAME: I u,'„ MC-8 rt jG I LICENSE NI 11ba U I SIGNATURE '� ITT /}�p_, n COMPANY NAME:IICP�v, McgrtidP Plum-F )Jrc+ —Enc. ADDRESS:I I) ( .rJrcPf' 1C)0:17t I CITY: ( w '/orrnQuill (STATE: GSI ZIP: ( mt,73 I FAX: ( TEL:Crig)—r,?-466 ICELL:I X64-71a4IEMAIL: I,( orcph As5 trim CC ,oe,+ I MASTER 0 JOURNEYMAN 0 LP INSTALLER 0 CORPORATION yJ# m PARTNERSHIP 0#©LLC❑#Q BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES ROUGH GAS INSPECTION NOTES 1-2- 1 R c aA4- Yes No (� v S THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: S PERMIT PLAN REVIEW NOTES •