HomeMy WebLinkAboutBLDG-16-003873 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-MOOif. CITY l�V ttxmo L ; MA DATE / `f i r PERMIT#
JOBSITE ADDRESS ‘2,?> U CSC//of K'I'*7 OWNER'S NAME $ZCZ Oa)
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: ✓ PLANS SUBMITTED: YES
APPLIANCES-I 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
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST f
UNIT HEATER
UNVENTED ROOM HEATER
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 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
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 an accura to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian/th al Pe -nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ken duarte LICENSE# 11012 ATURE
MP MGF JP JGF LPG! CORPORATION # 3541 PARTNERSHIP # LLC #
COMPANY NAME: duarte plumbing inc ADDRESS 37 collins ave
CITY centerville STATE ma ZIP 02632 TEL 508-250-2763
FAX 508-775-9135 CELL EMAIL kenduarte37@hotmail.com
L' ` f
ROUGH GAS INSPECTION NOTE THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Ek/� /)✓ O/L L/?/7 / 7/�'� Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES