HomeMy WebLinkAboutBLDG-17-001072 `&\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"f= CITY South Yarmouth MA DATE 08/30/16 PERMIT# f -4 --/'7—O/U72.
JOBSITE ADDRESS 36 Capt Blount Rd. OWNER'S NAME Keila Nascimento
GOWNER ADDRESS 36 Capt Blount Rd. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL✓
PRINT
CLEARLY NEW:j RENOVATION: ✓ REPLACEMENT: PLANS SUBMITTED: YES[! NOV
APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ! •
BOOSTER 1 1 i .
CONVERSION BURNER i
COOK STOVE I
DIRECT VENT HEATER
DRYER
FIREPLACE -'
FRYOLATOR 1 .
FURNACE l _ .
GENERATOR
GRILLE .
INFRARED HEATER }
LABORATORY COCKS I I ! j
MAKEUP AIR UNIT
OVEN
1
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT '
TEST —a
UNIT HEATER / t � ......1UNVENTED ROOM HEATER
i a
WATER HEATER
OTHER test. 1 1 1 ,_
i t i 1 i i .
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 El
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
1 hereby certify that all of the details and information I have submitted or entered regarding this application are true an a e to the best of my`Icnowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c ance with all Pertinent provision o th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Virgilio Silva LICENSE#31395-J SIGNA URE
MP MGF j JPt✓ JGFI I LPGIi i CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME:Silva Plumbing&Heating ADDRESS 155 Sudbury Lane
CITY Hyannis STATE MA ZIP 02601 TEL
FAX CELL 774-836-0176 EMAIL virgiliomga@hotmail.com
LR C77 9 t(b
\,D
N
ti