HomeMy WebLinkAboutBLDG-17-003360 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
, , ,_�[
e l"G2fF; CITY (d a ywp I't MA DATE PERMIT#4-1.17-/7---O0'5%90
.:gip J
JOBSITE ADDRESS 2. ► B %V4TO o 4 OWNER'S NAME
6509)
OWNER ADDRESS TEL 3 I - 55 S FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL x
PRINT
CLEARLY NEW: RENOVATION:k REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 7 FLOORS-4 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 ` r
OVEN
POOL HEATER
ROOM 1 SPACE HEATER Q 56
ROOF TOP UNIT
TEST :�. .-
UNIT HEATER t'
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 kn edge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertrovisi the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER-GASFITTER NAME TIM MCELROY I LICENSE# 15993
MP - MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:CAPE COD MASTER PLUMBERS,INC I ADDRESS 70 CRANBERRY HWY P.O.BOX 756
CITY SAGAMORE I STATE _ MA I ZIP 02561 ITEL 508-317-5525
FAX CELL EMAIL