HomeMy WebLinkAboutG-14-1023 /P -Z
S . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
17 i 3. ��'rli� CITY yarmouthpos.r MA DATE (o-2-H PERMIT# A/9-- 7
JOBSITE ADDRESS 35 aunt dorhas lane OWNER'S NAME Pal Co v Ricci pot,a t 1...,--
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G OWNER ADDRESS Terv,4- • TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL El
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CLEARLY NEW:❑+ RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES❑ N00
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER ;
DRYER
FIREPLACE ij I
FRYOLATOR /
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FURNACE __
GENERATOR Ad11111.1101111.ant 7» 11110_T���;�n :
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MAKEUPAIRUNOCKS �� nnn�I� a((lee(
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INFRARED HEATER _
EATER
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ROOM POOL/SPACE HEATER r� 1� 1 �MN�� or
ROOM
ROOF TOP UNIT
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TEST
UNIT HEATER
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IJUN . 4 201'1
,re,(/"/' INSURANCE COVERAGE
I h.v• , urren la r r y insuranc• ,•licy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑+ 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 permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true a urate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In comps nce th II Perllpent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME paul gens LICENSE#1r1 SIGNATURE
MP❑ MGF❑ .JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP 0# LLC 0# 3329
COMPANY NAME: pmg mechanical systems lIc ADDRESS po box 797
CITY forestdale STATE ma ZIP 02644 TEL 508 888 1745
FAX 508 888 3745 CELL 508 873 9657 EMAIL pmgmechanical@verizon.net
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P‘LyVA\3 1AI C--. • ACKNOWLEDGEMENT OF PARTICIPATION IN TRAINING
of Viega's installation Instructions -
3/Q Sp e- CA-C & , Name: Paul Gans
. Product Line: NlecaPress
District Manager Mike LaMountaln
Credential t: 14414 Date: 119/2014
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MG MECHANICAL SYSTEMS LIG ••••': : .I, . ., PAULIN GENS
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PLUMBETiS:AND ,GASf:ITTERS':
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FOLLOWING'LICENSE : 2 ,..ti - ASSASTER-UNRESTRICTED . i ..
• ISSUES THE ABOVE LICENSE TO:
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• LICENSE NO. EXPIRATION DATE SERIAL NO.