HomeMy WebLinkAboutG-12-251 Ls 1/4_SZ. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY I Yarmouth I, MA DATE I /al 2E—// I PERMR#6 2- off$-!
JOBSITE ADDRESS kc}-2 7 Ld cti w,r 4.,nae.9 R04 I OWNER'S NAME I H,.i72 1/ . I
G OWNER ADDRESS: I I
TEL: I TYPE OR (F�'I I
PRINT
OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0
PLANS SUBMITTED: YES 0 NO 0
FIXUTRES 1 FLOOR-+ Bsmt 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
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP MR UNIT
OVEN
POOL HEATER
ROOM 1 SPACE HEATER
ROOF TOP UNIT F t = "�
TEST , ' / A
UNITHEATER
UNVENTED ROOM HEATER 02V201' t
WATER HEATER —
B ILUI! L i.crA. —1 1
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COVERAGE
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I have a current liability Insurance policy or its substantial equivalentCwhich meets the requirements of MGL Ch.142 YES, f NO 0
If you have checked yam,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY PA OTHER TYPEINDEMNfTY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havq the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application slim this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that all of the detals 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 corn (lance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFTTTER NAME J i .rry G Ycr...k a I LICENSE It 02 .l TUB
' COMPANY NAME: IQvc ). b(e ?\ti,-.13,4; F krc_-r,• 7 IADDRESS:I (3cic to2_5 I
CITY: I]U Eas'h...-, ' ISTATE rAla zIP: I oz6'c/ I
I FAX: (
TEL: (5o C--2-'3 7-3 F 77I CELL:I I EMAIL' rl cry-C-Le 611.,...-1-)cr ei w,camas r, A t_r- I
MASTED JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0 ft LLC 0#1I
FINAL INSPGCI'!ON NO �S
BELOW FOR OFFICE USE ONLY
ROUGH GAS INSPECTION NOTES - -
Yes No JJ(
THIS APPLICATION SERVES AS THE PERMIT 0 0 lI/afAe-- OIL r �j
FEE: S__-- PERMIT f f✓
PLAN REVIEW NOTES