HomeMy WebLinkAboutG-14-606 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�= CITY: // MA. DATE PERMIT:
JOBSITE ADDRESS: 1/ ,4.&I/v&TO� OWNER'S NAME:A/AW
G! NY.�N/V15 /Y/ nF� SO 744- °
OWNER ADDRESS: S612f TEL 8 /3CJ F
PE OR OCCUPANCY TYPE: COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL 0
PRICLEARLY NEW:® RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO4S1
APPLIANCES? FLOOR I Bsnt I 1 12 3 4 5 8 1 7 1 8 9 1 10 111 1 12 1 13 I 14
BOILER II I
BOOSTER
CONVERSION BURNER I I I I
COOK STOVE I I I I I
DIRECT VENT HEATER / /110a/Ng
DRYER
FIREPLACE I I
FRYOLATOR I I I I I
FURNACE _
GENERATOR I 1 I
GRILLE I I I I
INFRARED HEATER I I I I
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER I • I
ROOM/SPACE HEATER
I ROOFTOPUNIT I I I
TEST
UNIT HEATER I I
UNVENTED ROOM HEATER I I I _
WATER HEATER I I I I
• I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES I l NO ❑
If you have checked YES please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND•
❑
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 applcationwaives this requirement
CHECK ONE ONLY: OWNER ❑ 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 a.. : best of my
Knowledge and that all plumbing work and installations performed under the perml issued for this application will be' come all Pertinent
provision of The Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFIi r tittdAME Pith ZeRAte LICENSE 4,44086 SIGNATURE---
COMPANY
IGNATURECOMPANY NAME: bin GE/.NE ,°te ADDRESS: /
CITY: k/YA,e4'cvf1I STATE //111ZIP:a2Z73 FAX: &t3 3?4 2S07
TEL CELL EMAIL RECEIVED
MASTER® JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑a PAR'NE2SHPP❑# I I C ]#
DEC 1I, a luIT
eilataFrm 110(g)
By
OUGI1 'AS IN.I'E . • ► • .YeTILLS PAGE FOR JNSI'ECTOItUSE ONLY lrlNALINSPECTION NOTES
0 4_5 DN LPH- Yos No
MIS APPLICATION SERVES AS TI IE PERMIT ❑ ❑
FEE: $ PERMIT I
FLAN REVIEW NOTES
•
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