HomeMy WebLinkAboutBLDG-21-000100 inA-p: 0-141GFL:
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
m'. - t CITY [S0.11tilYarCT10t1S11: us MA DATE 71/1/2020 1 PERMIT# ' 126'&/•-caricl
JOBSITE ADDRESS CA(� ) to rmac er R1 1 OWNER'S NAME CCoelho ]
GOWNER ADDRESS ame J TEI _ _ FAX[---_T,7„__
TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL fl RESIDENTIAL LA
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CLEARLY NEW:0 RENOVATION:Li REPLACEMENT:[-] PLANS SUBMITTED: YES Li NO(Xi
APPLIANCES Z FLOORS a 4liallr10gp14
BOILER BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _{I ;.. -I'` r- 1 ._. :_ _ '
DRYER - . • f - ,7..
FIREPLACE ,, M,_�&
FRYOLATOR „
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FURNACE . � - �
GGRILLE
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INFRARED HEATER
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LABORATORY COCKS
MAKEUP AIR UNIT ,
OVEN �_ ; ice. 1 1 _ II -
POOL HEATER MIN1117.- -r
- ___ _ - _..+ - 1 3L ..._ ...-ROOM)SPACE HEATER ! i i[ . iROOF TOP UNIT i; a w•1��
TEST _ _,. _ _ , _ _ „, _ _ _._ „,jimir___ __., .1, _.Ail., `,
UNIT HEATER
UNVENTEO ROOM HEATER sir i I I __
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WATER HEATER a. ? P
OTHER�—___ _ 1 1 I ., 0 =
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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 Ud NO L]
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Fa OTHER TYPE INDEMNITY [, BOND [1
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 La
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 knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J/- L _ p
PLUMBER-GASFtTTER NAME Herbert Healis LICENSE# 017.7 THY SIGNATUREIG.ITU
MP® MGF Q JP Q JGF® LPGI® CORPORATION #L_... _____J PARTNERSHIP®#[ I LLC®#[ J
COMPANY NAME:USA Mechanical _ _ .I ADDRESS! 78 Stu 1e -Rd ______I
CITY I South Yarmouth ______ .____I STATE I MA.JZIP[02664 : TEL 55088 776 5495
FAX __,_,���J CELL
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