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HomeMy WebLinkAboutBLDG-19-001553 • iL., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ili-t-.74--ct __,..„ , . --7;41----; arrinc-CounZ4-74.--7- :-- - -. i'ma DaTELT7tiop-I PERMIT,/ 0/106-17A7129 i 53-/ cc_ ) _ . •-•.' • „.. _________ S NAME J JOBSITE ADDRESSF-7r--.gici,sti ,,,...,,,„.., It. ;c: L.4:7)c_t _________.....__ . i r-•-%-- , G OWNER ADDRESS 1_, .TED TAXI_ - • *- TYPE OR OCCUPANCY TYPE COMMERCIALE** . EDUCATIONAL L.,.1 RESIDENTIAL 1771- PRINT CLEARLY NEW:E._!. RENOVATION:I_ ! RERAC ENIENT:lc------:,_ 4' ' PLANS SUBMITTED: YEST-1 N0,11 APPLIANCES 1 FLOORS-.- 881141 1 2 - 3 4 6 8 - 7 8 9 10 11 12 13 14 BOILER / , ... . - BOOSTER -., CONVERSION BURNER .... COOK STOVE . . ._ . , .. . . . . . . DIRECT VENT HEATER . . - ' -•' ' DRYER - . . -. . FIREPLACE • - • _. _ _ FRYOLATOR - FURNACE _ -- GENERATOR . . . .. .. . . GRILLE . ,.. , . . .. __ ._ . INFRARED HEATER . . LABORATORY COCKS ' . - ' MAKEUP AIR UNIT ' . . OVEN . - ' - - - -'•-- "`"- ---— POOL HEATER . ... . . .. . . . . ROOM I SPACE HEATER • . . . . ROOF TOP UNIT TEST - UNIT HEATER - . _ . . , UNVENTED ROOM HEATER , ... _ _. ... _ _ ._ _ _ _ .. . ,.. , . .. . . - - " • . _ WATER HEATER ' OTHER_i_ — - - - ' . , - . . - . . - - ' - ' ' INSURANCE COVERAGE I have a anentliability insurance policy orb substantial equivalent which meets the requirements of MGL Ch.142 YES IT NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW _ LIABILITY INSURANCE POUCY,_,!., . , OTHER TYPE INDEMNITy17.2i . . BOND 12.; OWNER'S INSURANCE WAIVElt I am aware that the licensee does almtg the insurance coverage required by Chapter 142 of the Massachusetts General Laws and that my signature on this permit application wing this requirement. • , - - • CHECK ONE ONLY: OWNER 1171 AGENT 1...„; ' SIGNATURE OF OWNER OR AGENT " - I hereby certify that allot the detail and Somalian I have etbnetted or entered regarding tits application are true and accurate to the beat of my knowledge and that all plumbing work and Installations performed wider the permit Issued for this application sVd1 be In compliance with all Pertinertprovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - C41.(41,11- cc PLUMBER-GASFITTER NAME;Mark Couto j LICENSE it!15856 . SIGNATURE MP i e7 MGF, 1 •JP r 7.I. AGE 1 1 UDGI r-7, • CORPORATION:;:8 1.34087 PARTNERSHIP-787 LLC Titi i. . ... ..... COMPANY NANIE.:1 Mark Couto Plb&Mg Inc. ADDRESS i 103 Lake Shore Dr .... ., . ...__ . ._ ...... . . , . . . • _ CITY :.Brewster , STATE. IAA -ZIP.02831 • !TEli 508-98.5-2145 . FA)(:508-896-2577 . •i CE1.1.; . IEMAILITialkicoulo@Yafloo.com -Iii.:E-C-E -I-V-L•D- ---' 4fAIS/a. . .. . . .. . . , . . .. . . . . - SEP 02,W . _ r . BUILDING PARTMENT 4• /244-- By (---. I ,. I I -- — _—. _ 1 1 _. .__._ ___.____._ . _. _.. _.. ...__ _..__I.-__ I I _- _ _- __ - _ __ .. _ _ __ -_- _j- _ _._ ._. _ ._ _._ _ _. - 1 -f 1 1 1 , 1 i 1 1 , I 1 , �^ 1 I I _I e .I _..�. 1 ..i . Vps 1 1 + - i