HomeMy WebLinkAboutG-13-399 nt MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS�U/r'T I�{/�Y� � � NAOWNER'SE .rA/ J
GOWNER ADDRESS EL1fVz%i72aFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIALLI
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CLEARLY NEW:O RENOVATION:❑ REPLACEMENT:O PLANS SUBMITTED: YESU NO[]
APPLIANCES 7 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _i _ �,_ ..,..I s . -a .,..._. _L __ i m_.I . m_E
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BOOSTER li__. .__..-I .. PI
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CONVERSION BURNER
COOK STOVE III IIII . IIIII,
DIRECT VENT HEATER 1 i _ • I I I ri I -4 I I :
FRYOLATOR '
GENERATOR MIIIIIINIMMINIMMIMIll
GRILLE NNNNNN11IUMEII I QN_.111
INFRARED HEATER 11011SIIIIIIIiiiMISIMININIIIIIIMINISINO0.11111111011
LABORATORY COCKSYM_
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-••M/SPACE HEATER i r I rra�-I nuc-'rlI ._J .,_.,_.:I —.r-f __.�...I
ROOF TOPI' 1 I' I, i ;,
TEST __. sormaintarni
UNIT HEATER
UNVENTED ROOM HEATER 1111.111101111111111.11011111111.1.111011111111111.11.111101111111111111110111
WATER HEATER I IKII _ IIIIIIIMI MIESI MINIMI IN 1 1N ISIMISKIM INNN1
OTHER 1111111110111111.01111110101111111010111001111101111.111011011011141.111010111
ISIMES11.10.11111101111.11MINIIMICIIIIIIISINIIIMES
IIIMONNERIMEMINIMMISIONIMINIMISINIIIIIIMINIIIIIPS
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO ❑
I IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 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 waives this requirement.
CHECK ONE ONL • N ,// 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-n• _•,,„1 a 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• all -ertinent•o '='• of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Air
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PLUMBER-GASFITTER NAME[Phillip Durfee l LICENSE# 13774 `/ SIGNATURE
MP[] MGF 0 JP 0 JGF 0 LPG![❑ CORPORATION 0# PARTNER/IP 0#j 1 LLC E # 3152 1
COMPANY NAME: Durfee Plumbing and Heating,LLC ADDRESS 2A Huntington Ave.
CITY South Yarmouth STATE MA ZIP! ..4 1 r:-• •- 78
FAX 508-258-0592 !CELL 508-801-8004 EMAIL phil@durfeeplumbins.com 2 0 leul \ I
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BU:LOING DEPT
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