HomeMy WebLinkAboutG-13-817 • g/CC s pg.- fl- odoa
2L.` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
cr-''' CITY (Yamauth J. Mk DATE I - -/ J I PERMIT# v/h
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JOBSITEADDRESS I ') Ca iit.c 91? I OWNER'S NAME I t 11Nra Rea/75/ I
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TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL IM-----
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:r PLANS SUBMITTED: YES 0 NO❑ .
FIXUTRES 1 FLOOR-, Bang 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
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST L.---
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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I have a current liability insurance policyor its substantial INSURANCE COVERAGE 1'9
equivalent which meets the requirements of MGL Ch.142 S • 11 ,
If you have checked yes please indicate the type of coverage byc Intim-appropriate box below. I CD
LIABILITY INSURANCE POLICY tr OTHER TYPE INDEMNITY MAR 8 ��
❑ BOND
OWNER'S INSURANCE WAIVER:I ant aware that the licensee does not hal the insurance coverage required by Chapter 42 of theu'uol
Massachusetts General Laws,and that my signature on this permit application waives this requirement Uy --
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑
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 .. • .. pllance . th all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTERNAME I STEi(h, ¶t'r r rr I LICENSE#I//S/7 I SGNATURE
COMPANY NAME: I $.3 %;ec_,• Q :..&. IADDRESS:I -6 G,/d4/M1 y Da I
CITY: I .7,46,.i cit-_,,r (1 I STATE l ZIP: I CZ 6Th 7 J FAX I I
TEL[ (t Ir- Woo--,--ec. J CELL I ba+n-t- I EMAIL 11S R.ec, Cps d 6) Gma,'/. Crrn I
MASTEROURNEYMAN 0 LP INSTALLER 0 CORPORATION 0#I (PARTNERSHIP 0 if LLC 0#
fiOn- 66-9 ox ,-,e/t s/hJ/3