HomeMy WebLinkAboutBLDG-16-005075 LN,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY MA DATE 47(' 42 (PERMIT# /9146 -4-9O X'7,
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JOBSITE ADDRESS �,r�/ I/GIB Qi r4A 4'\'(;G,, - OWNER'S NAME 31 1
GOWNER ADDRESS L - - I FAX i
TYPE OR OCCUPANCY TYPE COMMERCIAL 7-1 EDUCATIONAL r ' RESIDENTIAL f
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:'✓ PLANS SUBMITTED: YES I NO ''
APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER v 1 ----. 1— -__
BOOSTER ! '—�. - ,
CONVERSION BURNER `
COOK STOVE _ .W_1
DIRECT VENT HEATER ,
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DRYER L , i II —
FIREPLACE � _,r r `�1 i
FRYOLATOR �� k`
FURNACE 1 , 11 I: +r —
GENERATOR
GRILLE
INFRARED HEATER r
LABORATORY COCKS I I u _
MAKEUP AIR UNIT
OVEN L_
POOL HEATER
ROOM I SPACE HEATER E Ir —4--- -
ROOF TOP UNIT I
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TEST �.:.
UNIT HEATER L: '
UNVENTED ROOM HEATER I
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 I , NO s_ !
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY , OTHER TYPE INDEMNITY BOND 1 ''
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 tq,the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli with ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Filiip Durfee LICENSE#113774
MP MGF,_:1 JP LJ JGF❑ LPGI El CORPORATION D#1` PARTNERSHIP # �LLC Q# 3152
COMPANY NAME Plumbing&Heating LLC 'ADDRESS 2A Huntington Ave.
CITY South Yarmouth ! STATE MA ZIP 02664 JTEL 508-619-3078
FAX 508-258-0592_j CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;joy@durfeeplumbing.com 1
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