HomeMy WebLinkAboutG-14-849 ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ACITY .1 'Ioi9n1 ... MA DATE 'IG 1'±'l$ i PERMIT# �� _ fr
JOBSITE ADDRESS 5Q/ 6 ism/fa/19, 0W OWNER'S NAME CARO )gay /'201?
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: _ ; RENOVATION: __i REPLACEMENT: _; PLANS SUBMITTED: YES .' NO
APPLIANCES 1 FLOORS BSM 1 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
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
I INVFNTE2EPOM HFATFR
WFTER'HUTEIVED
OT
I.•MAR.142014
BUILD IN(fl \RTMENT INSURANCE COVERAGE
S have a current GASility insuranc policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I ' NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
r LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND I .`
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.
CHE 0 ONLY: 0 R AGENT _
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this applicatio are true nd accurat to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be n complia ice with all inent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Dennis Devine + LICENSE# 11741 G RE N
MP ' MGF JP JGF LF'GI CORPORATION v # 2931 I PARTNERSHIP '# LLC #
COMPANY NAME:Devine Plumbing&Heating Inc. I ADDRESS 8 Jan Sebastian Dr.#23
CITY Sandwich I STATE MA I ZIP 02563 ITEL 508-888-9002
FAX CELL ;EMAIL
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