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HomeMy WebLinkAboutG-14-364 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rr_3 e� CITY: We Sr �o-f•Kaa MA DATE 10-7I-l3 PERMIT# b/y;6/ JOBSITEADDRESS: 2- Acres 4ue OWNER'S NAME Pere N (f 1 oilG OWNER ADDRESS: ).•.1- Otres Au e...- a FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL©- ? PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO I3 APPLIANCES? FLOOR-. Bsmt I 1 12 3 1 4 5 55 17 18 9I1011112113114 BOILER I I I I 1 I BOOSTER 6 Ju CONVERSION BURNER I I I I I I I I I I \k COOK STOVE I S�13Lgcy DRYER DIRECT VENT HEATER 1 I I — " I I I I FIREPLACE I / I _ FRYOLATORI I I ^�! (L' j FURNACE I I I v I �" 9 P.. Dr _ '_ . I I 1 - GENERATOR I I . 41 ililY / 1 L GRILLEI Y ! OCT 2 i 201 I (- I INFRARED HEATER I I LABORATORY COCK I — I_ J MAKEUP AIR UNIT I I I rkal i 4;/� , OVEN I I I I _— r POOL HEATER I I�ggyyy ROOM/SPACE HEATER I I I I J�j•c-4Oa . I ROOF TOP UNIT I I J V TEST 4-4 I I UNIT HEATER UNVENTED ROOM HEATER I I WATER HEATER 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 0 NO 0 Ifyou have checked YES please indicate the type of coverage by checking the appropriate box below. LUABILTfY INSURANCE POLICY 2 OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAVER: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 wakes 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 application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,_ PLUMBERIGASFII1 diNAME: KEVIN ItlF•Ettela LICENSE# 1189- SIGNATURE COMPANY NAME M EEff4N OLC; .t lir& ADDRESS: R O- 35-8-33 CITY• goS'6in STATE /Hr• ZIP: OJ•13C FAX nn TEL caL•Set-2VI- vrrio Emu ?. r�i- 004 @ /to trruoZ.co"-. MASTER E1--151JRNEYMAN 0 LP INSTALLER 0 CORPORATION❑# PARTNERSHIP 0# LLD 0 it OUGI[GAS PIM1. O 1 • 'S pus PAGE FOR INSPECTOR USE ONLY FINAL'vs I'GCI7ON NOTES G� DYc G2 iY /0 4 l 13 Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE: $ PERMIT4 FLAN REVIEW NOTES