HomeMy WebLinkAboutBLDG-19-006161 - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_�- =: - CP/CP•�J�=- CITY South Yarmouth MA DATE 4/15/2019 PERMIT#����
JOBSITE ADDRESS 25 Vine Brook Road OWNER'S NAME Demitri Riskal
GOWNER ADDRESS 25 Vine Brook Road TEL 339.970.1133 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO
APPLIANCES- FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
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/SPACE HEATER
ROOF TOP UNIT
TEST
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 i NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i 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 1 have submitted or entered regarding this application are true and accyratato t est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian v 1 h anent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Phillip Durfee LICENSE# 13774 SIGNATURE
MP i MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC i # 3152
COMPANY NAME: Durfee Plumbing&Heating LLC ADDRESS 12 American Way#1
CITY South Dennis STATE MA ZIP 02660 TEL 508-619-3078
FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;sales@durfeeplumbing.com