HomeMy WebLinkAboutBldp-20-000294 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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kL.72-7•5 r PARCEL MA DATE 7/17/19 I PERMIT# v O y
JOBSITE ADDRESS 25 Mitchelles Path west yarmouth I OWNER'S NAME William Grteene Jr.
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
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN 2
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER T�
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance 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
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.
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„.1,1, best of m
and that all plumbing work and installations performed under the permit issued for this application will be in compliance . =nt • ' on of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Michael Pereira LICENSE# 10600 I � -NATUR -
MP . MGF ° JP JGF LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:M.D.Pereira PLG.&HTG. I ADDRESS 27 Lawrence Ln, J
CITY Centerville I STATE Ma I ZIP 02632 I TEL 508-790-2686
FAX CELL 508-776-5846 I EMAIL usermvp8181 Qaoi.com
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