HomeMy WebLinkAboutG-14-040 Lc:N. MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
es CITY: NOof 'MO v\A". MA DATE ^I' go -L3 PERMIT# /2,11-0g°• JOBSITE ADDRESS:35(Grn P� p10 vi OWNER'S NAME / , 1/ Co aZ 1
GOWNER ADDRESS: TEL' _ FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW�RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR Bsmt 1 2 I 3 4 5 o I 7 1 8 9 10 111 1 12 I 13 1 14
BOILER I I
BOOSTER I
CONVERSION BURNER I I I
COOK STOVE I I I
DIRECT VENT HEATER
DRYER I l _
FIREPLACE • I I I
FRYOLATOR I I I I
FURNACE I /I
GENERATOR I
GRILLE I tyy,_4
INFRARED HEATER
LABORATORY COCK 'I / '
MAKEUP AIR UNIT V
OVEN
I POOL HEATER I
ROOM/SPACE HEATER
I ROOF TOP UNIT
TEST I I
UNIT HEATER I
UNVENTED ROOM HEATER I
WATER HEATER
I
1-
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YENO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY DC._ OTHER TYPE INDEMNITY 0 BOND 0
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 0 AGENT 0
SIGNATURE OF OWNER OR 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 applicatio in co rlianc-ith all Pertinent
provision of the Massachuser Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASF NAME: V k2SGL LICENSE
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SIGNATURE
COMPANY NAME A'U\S P`CNhCD( 40y ADDRESS: C3 lll.5 O<...
CITY::/ SvJC C k.-\ E
STATE: ZIPQQ&qFAX
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MASTER 0 JOURNEYM LI;INSTALLER❑ CORPORATION 0 II PART1ERSFI!P❑# LC❑#
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