HomeMy WebLinkAboutBLDG-16-004104 __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1"t=1=' CITY YØm1i24fh 12 (+.•
, MA DATE IL 2-�11/ PERMIT# P'l i --74( W `', (
JOBSITE ADDRESS; 3 OWNER'S NAME , I iOof -try) 1
GOWNER ADDRESS ;TEL{'� - ` FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL i] RESIDENTIAL Ei
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES"-, NO!w
APPLIANCES Z FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I'
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BOOSTER r ,r- , _ __ _.�__._
CONVERSION BURNER ---
COOK STOVE T ,` i
DIRECT VENT HEATER I _ _ r I,--- ._,....
DRYER ;ice
FIREPLACE -- _
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FRYOLATOR r
FURNACE It __
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GENERATOR
GRILLE
INFRARED HEATER MI ,I
LABORATORY COCKS
MAKEUP AIR UNIT "': r4
OVEN , __4r-_ _.
POOL HEATER - --- -
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ROOM/SPACE HEATER l -11-- _- .._ _ : E
ROOF TOP UNIT [ 1---
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TEST __ r 1- ! ___ _ _
UNIT HEATER iJ - li --� _. IL
UNVENTED ROOM HEATER 1`� r-
WATER HEATER 1 - _ �
� OTHERI 1
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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 Li 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• OW ,‘ R 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 a•ol!"'to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia - Iw:11 Pe, = t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Phillip Durfee LICENSE# 13774 iv SIGNATURE
MP i MGF __, JP J JGFL LPG'ID CORPORATION # PARTNE' IP®#F —1 LLC m#r3152 _1
COMPANY NAME Durfee Plumbing&Heating LLC ADDRESS 12A Huntington Ave.
CITY (South Yarmouth I STATE! MA I ZIP 02664 HTEL 508-619-3078
FAX i 508508-258 5050 92 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;joy@durfeeplumbing.com
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