HomeMy WebLinkAboutBLDG-19-001555 gtb, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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;taint-.i �" UI' . I€1 tVt PILE - _._ __ • ! MA DATE iql[Y TJPERMIT 8/Ots- -02/533 "
JoBSITEADDRESS~-,lar Qr6,4 . . iOWNER'SNAME .Cb-UFt±-�,t._ 0fe
GOWNER ADDRESS 1 =_..-,- ITa. _. __..____ _ rF
TYPE OR OCCUPANCY TYPE COMMERCIAL'�-� EDUCATIONAL. RESIDENTI AL7 71
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CLEARLY NEW:UU! RENOVATION:i_' REPLACEMENT:'T�-•-r- . . PLANS SUMMED:-
TESL:i NO j
APPLIANCES Z FLOORS-0 • 8SM 1 2 3 4 5 8 - 7 8 9 10 11 12 13 14
BOILER I
BOOSTER
CONVERSION BURNER
COOK STOVE _ . . _ r . ._..- - . . _
DIRECT VENT HEATER
DRYER
FIREPLACE _ .
•
FRYOLATOR -
FURNACE
GENERATOR •
•
GRILLE - . ... . . . _ . . . - . . _ - -- __ -
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNI -
OVEN - - -
POOL HEATER - - - -
ROOM/SPACE HEATER - _ .
ROOF TOP UNIT - -
TEST .
UNIT HEATER
UNVENTED ROOM HEATER - .- :. •
. . . . . .
WATER HEATER: ._. .
OTHER! .__
' INSURANCE COVERAGE
I have a current jlability insurance policy or its substantial equivalent which meets the requirements of Ma.Ch.142 YES f I NO '-'
I IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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UABIL TY INSURANCE POLICY I OTHER TYPE INDEMNITY 17.2 . BOND {..-; -
OWNER'S INSURANCE WAIVER:I am awe that the licensee does not have the Instance coverage retprfred by Chapter 142 of the
Massachusetts General Laws,and that my signatreonthis permit application waives this requirement.
.• CHECK ONE ONLY: OWNER El AGENT fl ' .
• SIGNATURE OF OWNER OR AGENT . - -
I hereby certify that all Cl the&stab and Yttamaton I hew submitted or entered reg&dMg tits application are tar and accurate to the best of my knowledge
and that all plumbing work and Installations performed Lauder the pent issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Cods and Chapter 142 of the General Laws. - �f..k- �. 1
PLUMBER•GASFITTER NAME;Mark Carlo ;LICENSE W 15850 . SIGNATURE
MP i r • MGF'' •JP 7-1 AGF t�'; 1,617 CORPORATION'+';1{'3401-7� PARTNERSHIP—C. - LLC' #�T�-_.
COMPANY NAME:Mark• Couto Pib&Htg Inc. ADDRESS':103 Lake Shore Dr
CITY ;Brewster STATE MA 'ZIP.02631 ' 1E11508-985-2145
FAX;508898-2571 .iCELL;_- . . _,.. 1EMAILIMM Y am _.r te =-R-E CE-V'E D 3�J
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EP 13 2018 ��
BUILD! EPARTMENT
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