HomeMy WebLinkAboutBLDG-19-001259 � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_
?"F1= • CITY LSJv,T1,� '17
) ►912tf -y J MA DATE Lir/Zf f( JPERMIT#
JOBSITEADDRESS L(/2—SoUSH• SHon_ R9__1OWNERS NAME{Jv37fv ,CL'6OZ77 i
GOWNER ADDRESS TELT /'FAX[ t
TYPE OR OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL RESIDENTIAL r:/Xe.
1-
PRINT
CLEARLY NEW:Q RENOVATION:Q REPLACEMENT:Li PLANS SUBMITTED: YES[I NO(, --j
APPLIANCES 1 FLOORS–. BSM 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
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT •
OVENRECEIVED
POOL HEATER l
ROOM!SPACE HEATER
ROOF TOP UNIT AUC 30 2)10 '
TEST /
UNIT HEATER ,
UNVENTED ROOM HEATER , OUIL 4 8750,5 7
WATER HEATER IJJ �f
OTHER
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES E)NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY Q 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 Li AGENT U
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 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 1:11: 17e with rtinent ovisionsof the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME David A.Whelan —I LICENSE#j 13046 ) SIGNATURE
MP 0 MGF Q JP Q JGF Q LPG]Q CORPORATION 0# PARTNERSHIP E#[y J LLC E#__. I
COMPANY NAME: David A.Whelan Plumbing&Heating 1 ADDRESS 167 Crawford Road
CITY Cotuit 1 STATE LMA JZIP C2635 ITELL774-238-2340 I
FAX CELL {EMAILLdaveawheian@gmail.com —�
i
I
t
i
I
i
f