HomeMy WebLinkAboutBLDG-17-004964 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
e Val sr-, CITY West Yarmouth MA DATE 03/23/17 PERMIT# BZ-1)6 f7 -00 / 741-
JOBSITE ADDRESS 41 Higgins Crowell Rd. OWNER'S NAME Daniel Xavier
GOWNER ADDRESS 41 Higgins Crowell Rd. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER
FIREPLACE '
FRYOLATOR
FURNACE 1 ,
GENERATOR \UO
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER r - —_
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 and accurate to the best of my knowle ge
and that all plumbing work and installations performed under the permit issued for this application will be in corrjpliance with all Pertinent provision oft
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME VVlrgilio Silva LICENSE# 31395-J SIGNATURE"
MP L_ MGF JP 171 JGF LPGI L. CORPORATION # PARTNERSHIP0# 'LLC #
COMPANY NAME:Silva Plumbing&Heating ADDRESS 155 Sudbury Lane 1
CITY H annis STATE MA ZIP[02601 TEL
FAX f CELLI774-836-0176 EMAIL virgiliomga@hotmail.com