HomeMy WebLinkAboutBldg-19-006611 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
F �'I i= CITY ion 1 vo v-t 1 MA DATE c /z o),7 PERMIT# � 4G"/�` ° ��`I
JOBSITE ADDRESS 2'y /4066.7 10-F OWNER'S NAME c'Nn%s'77'J'i/t'7 D /cEFfE
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL p/ RESIDENTIAL J/
PRINT
CLEARLY NEW: ,, RENOVATION: REPLACEMENT: ✓ PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS—I 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 ;,
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT ; ,
TEST , t
UNIT HEATER
UNVENTED ROOM HEATER , M i 701j ,
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 v NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY v OTHER TYPE INDEMNITY BOND
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 to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com,D'J ce with II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Z-- 4<.
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PLUMBER-GASFITTER NAME; David A.Whelan LICENSE# 13046 SIGNATURE
MP >�.I MGF _` JP JGF , LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME.' David A.Whelan Plumbing&Heating ADDRESS 67 Crawford Road
CITY Cotuit STATE MA ZIP 02635 TEL 774-238-2340
FAX CELL: ;EMAIL daveawhelan@gmail.com
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