HomeMy WebLinkAboutG-13-110 MASSACHUSETTS UNIORMAPPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• �— CITY: j i'c�av6 MA. DD TE: v J /,/,J PERMMIT# b✓//0`/
JOBSII�PESS:/ /`/dI/% jli7/L(,C/ 4.v'1- / OWN N IE !l C1Ul)" L9/7(
GOWNER ADDRESS: TEL ieeVo FES '5%+r LD e-2
TYPE OR OCCUPANCY TYPE: COMI ERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 2'
PRINT — /
CLEARLY NEW:0 RENOVATION. REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO L�
APPLIANCES1 FLOOR I Bsmt 11 12 3 1 4 1 5 6 1 7 1 8 1 9 10 11 I 12 13 I 14
BOILER
BOOSTER I I I1 1
CONVERSION BURNER I 1 1 _
COOK STOVE I I1 1
DIRECT VENT HEATER I I
DRYER
FIREPLACE I
FRYOLATOR F I I I 1.
FURNACE I Z F ft Pi V F _
GENERATOR
GRILLE L
INFRARED HEATER J N 2 a 1014 r I _
LABORATORY COCK I I
MAKEUP AIR UNIT [ tLIILD,'id DE,PAR
OVEN r — ----
POOL HEATER I
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ROOM/SPACE HEATER
ROOF TOP UNIT
TEST I
UNIT HEATER I
UNVENTED ROOM HEATER
WATER HEAiLR I
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equip/�{alent which meets the requirements of MGL.Ch.142 YES NO 0
If you have checked YEa please indicate the type of coveragy checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 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 application v' , in • a fiance with all Pertinent
provision of the Massachusetts State lumbing CCood/�Chapter 142 of the General Law / ' "i
PLUMBEJGASFITTERNAME• d'47 ..70/ _. LICENSE
OC 2 `/ SIGNATURE
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COMPANNYY NAMEca-G 'y nett A✓ " ADDRESS:!o,y/�o* LL'' ✓//,i
CITY:0/l��Cf �p ��SS�TATE i.�/ ZIP:&0`�/f% FAX •
TEL: CELLg2'✓('7�O�?Oc EMAIL:
MASTER U JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0,a, PARTNERSHIP 0# LLC 0 R Cfa11
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