HomeMy WebLinkAboutBLDG-15-006156 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`:71_i y CITY FYarmOuth MA DATE 6-10-15 PERMIT# />LD 67/S GG 627 4'
JOBSITE ADDRESS 76 Pompano Rd —I OWNER'S NAME Hal Smith
GOWNER ADDRESS same TELj FAX j
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL fl RESIDENTIAL Li
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CLEARLY NEW:n RENOVATION:❑ REPLACEMENT:Li PLANS SUBMITTED: YES❑ NO
APPLIANCES Z FLOORS—, BSM 1 l 2 3 4 5 6 7 I 8 9 10 11 1 12 13 14
BOILER `l
BOOSTER I MR111111. Ill
CONVERSION BURNER M '
COOK STOVE _ J I I
DIRECT VENT HEATER I I
DRYER J Jr II
FIREPLACE J j r
FRYOLATOR J J
FURNACE 1 1J J
GENERATOR I I k
GRILLE 1
INFRARED HEATER i
LABORATORY COCKS 4iiii
MAKEUP AIR UNIT J
OVEN SIM MIEN��!
POOL HEATER111.111•11111111111.--H1111111111111111111111111
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ROOM I SPACE HEATERROOF TOP UNIT ,a __!� �;_,
TEST UNIT HEATERi1�(Il��! ss� __
UNVENTED ROOM HEATER El
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [d NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY !f OTHER TYPE INDEMNITY [ I 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 I I
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 e o of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com all n ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Ed Pavlu LICENSE# 11320 i NATURE
MP I ' I MGF JP❑ JGF Li LPGI CORPORATION Li# PARTNERSHIP❑#F LLC _#�
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COMPANY NAME: Pavlu Plumbing and Heating Inc. I ADDRESS P.O.Box 634
CITY ,Brewster STATE Ma ZIP 02631 --TEL
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FAX CELL EMAIL fasted7437@aim.com
r JUN 10 2015
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