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Home My WebLink AboutBLDG-19-003574 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1.~moi b=lfil a:n=E 0 : PARCEL MA DATE PERMIT# ei-Per"l—oo fly JOBSITE ADDRESS 25 Micheals Path yarmouth I OWNERS NAME Bill Green i GOWNER ADDRESS Same I TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO 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 C4er-e-/o. t FRYOLATOR _ FURNACE GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE r R r -f�.., have a current liability Insurance policy or Its substantial equivalent which meets the requirements o M I Ch.142 YES J -9 0 I IF YOU CHECKED YES,PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX B LO GtC 12 2016 J ' OTHER TYPE INDEMNITY euI�L,�o `�PARM LIABILITY INSURANCE POLICY BY 1—� �� dLyiTrj Cy OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by hapter 4 ofThe�v Massachusetts General Laws,and that my signature on this permit application w Ives this requirement. CHECK ONE ONLY: OWNER AGENT _ 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 o knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance al n vislo of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTERNAME Michael Pereira I LICENSE# 10600 I SIGNATURE MP -' MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC # COMPANY NAME M.D.PLg.&HTG. I ADDRESS 27 lawrence Ln. CITY Centerville I STATE Ma I ZIP 02632 I TEL 508-790-2686 FAX CELL 508-776-5846 I EMAIL usermvp8181@aol.com I zi if . _ . _. . . _ . . . •' . . ,.- .. - .. . . . - . . ... , • ... . . . • . . . -• , . . . . ., . . . . . . . . . . i .. . , • . , . . .. • ._ ' ,_ • . ' , ' . . . .. _ .. . . . . . . . • . , _ , . . . . - . . , , - . . . - - . , . . . .H . • . ., r . , . - . , , , . . ' ' . • • • . ' - • , , , . .- . . , . r . . , , . L . . . . . _ . . . 2 ._ . . . L . . . .. . . . . . , . . . . . . . , . . , • ' . . .. , . . . . . . . . . . . . . I . . _ . . . , .. , . . . . , - . , • . . ' . . . _ . , • .. . . .- . • • . . . . , . . , . . . . . . , . . . . . • ,. 2 . . . . , . . ,... . . - • . . . . . , . , , • . . . . . . . . . . . . . _ . , . . . . ' . . . . . ' . • - , ., • . . . ' .. - . I , . . . _ ,. . . . . .. . - _ , . . r , fr . . , . . . . • . . • , , . . . . , . . . .„ . . . . ... . , . . . , . ._ ., . ..., . . , . I . . , . . . . . • __ . ..