HomeMy WebLinkAboutLFADMIN 1/3/2019 2:12:52 PM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
. wT. . CITY I Yarmouth
I, MA. DATE I 10 --Ig—I( I PERMRt3( 2_0 21 Li
JOBSITE ADDRESS I up 6-roJSq/ Ant- IOWNER'S NAME I-3p1nn 4o,j k I
G OWNER ADDRESS: I Sq.rr,s2— I
TEL I
TYPE OR I FAX I I
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:
PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 1 FLOOR-, esmt 1 2 3 4 5 8 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
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER '
UNVENTED ROOM HEATER "
WATER HEATER
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I have a anent liability insurance INSURANCE COVERAGE
policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO a
If you have checked yes please indicate the type of coverage by checking the appropriate box below.
LIABILRY INSURANCE POLICY 0 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 ,and that my signature on this permit application waives this requirement
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SIGNATU-EOFOWN • IRA CHECK ONE ONLY: OWNER 0 AGENiA
hereby certify that all of i e 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 will be In compliance with al Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 9. ,
PLUMBER/GASFITTER NAME: I tioki-(n0.v� �c4$ov`4 LICENSE It MO SIGNATOR �A
COMPANY NAME I/Occ{FnoLex c'ct1
(� I ADDRESS:14 ad It,,,, t
CITY: I Co.n-4rxviLs 1 ISTATE ►l ''r ZIP: =9139 J FAX I !I
TEL I I CELL: S €s . : $ J
MASTER K JOURNEYMAN 0 LP INSTALLER 0 COR PO lick#161g4si.AFTNERSHIP 0#I_J LLC 0#I�
s
Aly/7/
B ILD (,DEPT.
By:
ROUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY NALION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: f PERMIT
PLAN REVIEW NOTES
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