HomeMy WebLinkAboutBLDG-19-004004 -- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
F CITY 1 YYILUf-h 3 MA DATE 1 I PERMIT# i)/--/9--OC 960>'
JOBSITE ADDRESS 4\1 O Id. CY1.0 V•Ch St- OWNER'S NAME
GOWNER ADDRESS 41 00 C\AW-CCn SA-. �. - I TEL 56i--3(0)..-3301 I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL t/
PRINT /
('LE.ARLI ' NEW V' RENOVATION I1 REPLACEMENT:[1 PLANS SUBMITTED. YES;. i NO a/'
' APPLIANCES 1 FLOORS BSM 1 ' 2 i 3 1 4 5 . 6 7 i 8 9 10 11 12 1 13 14
BOILER11111111111011111,1111111Mill 11111111111�°
—
,_.BOOSTER � pI i L.—�
I��� III I i rii
CONVERSION BURNER I iI I I I { II II . 1. 1' _ 1
COOK STOVE I I 1. '
DIRECT VENT HEATER _j II I j 1 II ,'__I
DRYER f, I' I 1
FIREPLACE IIL ,_(-_"`�' 1 ,
FRYOLATOR ---_ .,_ -
�- Ell 1
GENERATOR; FURNACE _ �I��`��l�ll . �
INN 011111a
GRILLE - URUURUaR
Mill®HEATER �
LABORATORY COCKS I f
MAKEUP AIR UNIT I I ( I II I h I 11 I 1
OVEN I I I ''I It II I it I, II I
POOL ROOMF/SPACE HEATER j�!�'I�I� +�1I�1 i
I
ROOF TOP UNIT I1 a I�
_I_
BMR
TEST UNIT �I I �I i �if�'M Eli W:
_ .�'�
OP IIIII WIN
UNVENTED ROOM HEATER I11111111111111111111111MitnillitaiiiiiiiiiganiglINIIIIIIII
WATER HEATER RII !!IiiiiIIi
11- _.
INSURANCE COVERAGE
• I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO Li I
. I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
I
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 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 co Ii nce i all Pertin t pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws
PLUMBER-GASFITTER NAME Clifford Sands LICENSE#113103 SI NATURE
MPr MGF JP JGF LPGI CORPORATION # PARTNERSHIPS# LLCQ#
COMPANY NAME:Master Tech Plumbing Inc. ADDRESS P.O.Box 876
CITY �Mashpee STATE MA. ZIP 02649 'TEL 508-444-2822
FAX I CELL508-444-2820 EMAIL Cliff@mastertechplumbingandheating.com
c: kcTT)