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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
jittri -I.w=r/ CITY Yarmouth , MA. DATE Iq-a9-/t I PERMIT eel 2► (&3
JOBSITE ADDRESS /7 Genera[ AcweM t. a OWNER'S NAME �Qi�ep COprJ4
GOWNER ADDRESS: I I TEL I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL['3(
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:' PLANS SUBMITTED: YES 0 NO
FIXUTRES 1 FLOOR-• Bunt 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 X
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 liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO 0
If you have checked 10,please indicate the type of coverage by cheddng the appropriate box below.
LIABILITY INSURANCE POLICY>4 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am 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 penult application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
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 II be com al Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTERNAME: I/Qrtl1e., 117-13. i 1 LICENSE# 7/97/ NATURE
COMPANY NAME: R LcPIVYrA4/V1q i1{�47 4 I ADDRESS: O•Rok) I S/ 1
Cm': IW. Herrulr%/A 1 ISTATE /1' ZIP: 1.00t 7/ I FM:
TEL: MintalPaWilll CELL: Pd 9Av Rei !t int-) " - 74 thin
MASTER 0 JOURNEYMAN 1: LP INSTALLER II CORPORATION❑#1aPARTNERSHIP 0#JI LLC 0#
SU' z 91011I
U
BUILDING DEPT.
ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS WE PERMIT 0 0
FEE: $ PERMIT
PLAN REVIEW NOTES