HomeMy WebLinkAboutBLDG-20-003955 -rr. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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1� '.4•7'.e CITY \ar 1 ,1(..)MA DATE 1' 'At PERMIT* A-176-' eg*T
JOBSITE ADDRESS ' CI R "- Q OWNERS NAME
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•. c OWNER ADDRESS -1 N; '' TEL 1gI 3S4-C,,7 FAX a- -�
I TYPE
9 OR
OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL RESIDENTIALX
NEW: y\ RENOVATION: REPLACEMEN1 PLANS SUBMITTED: YES . NO)
APPLIANCES Z FLOORS-. BSM : 1 2 3 4 ' 6 J-�
BOILER _.. -. 1 7 8 9 "0 11 '? 13 14
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BOOSTER _ '
' CONVERSION BURNER t... . . i — - . . 1 - ,.
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COOK STOVE
DIRECT VENT HEATER .-�.___ It _i_—t -,
DRYER :_ _ � 7 -f .... '-__ -! t_ -_, .. ... .. . _t_, ,__+_
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FIREPLACE +
FRYOLATOR 1 r-- --r--- ------ --- -�--1--- --�-
FURNACE ._.. ;. + . . .l fi H
i GENERATOR
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! GRILLE
I INFRARED HEATER t I .�
t.... . . i -- - ' If
LABORATORY COCKS I
MAKEUP AIR UNIT •
OVEN r- -�:+ t _ ____ �, .. i :� .
POOL HEATER
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ROOM/SPACE HEATER
ROOF TOP UNIT I 1
TEST _ --4- } I.... +- 1. _- . { ; t . . I
UNIT HEATER
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UNVENTED ROOM HEATER i
WATER HEATER,..-. -- r-- � � l ��. __ -1------- _..- _ _ ... _.t J.
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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 . 1
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 ereby 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 li nce ' all Pertin t pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , A i k
I I;PLUMBER-GASFITTER NAME Clifford Sands LICENSE# 13103 / SIONATURE
' MP = MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:Master Tech Plumbing Inc. ADDRESS P.O.Box 876 -
CITY Mashpee STATE MA ZIP 02649 TEL 508-444-2822
' FAX CELL 508-444-2820 EMAIL Ciiff@mastertechpiumbingandheating.com -
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