HomeMy WebLinkAboutBLDG-17-005718 .Z \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESSr'�3t-'t WI Y Y"/ 6-le_et.La 12 d OWNER'S NAME �k-10 Vi-fi Al� 014/11 i'LO I--v't
G OWNER ADDRESS TEL g 1
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TYPE OR OCCUPANCY TYPE COMMERCIAL/X. EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: ..X. 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
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN .
POOL HEATER
ROOM I SPACE HEATER
ROOFTOP UNIT
TEST:
UNIT HEATER . .....,_.
UNVENTED ROOM HEATER
WATER HEATER C .
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 • 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 kn Wedge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Per inrovisi the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -•----
PLUMBER-GASFITTER NAME TIM MCELROY I LICENSE# 15993 "—""`- E
MP MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME CAPE COD MASTER PLUMBERS,INC I ADDRESS 70 CRANBERRY HWY P.O.BOX 756 1
CITY SAGAMORE — I STATE MA I ZIP 02561 J TEL 5013-317-5525 J
rAX CELL EMAIL
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