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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CAM CITY: SlOrVP. ,. MA. DATE 5/i311 3 PERtfrf
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JOBSITE ADDRESS:.) 6 &fsy h -✓'rV Ad OWNER'S NAME:Pa M t Sr n,n D i—
G OWNER ADDRESS: ,Cnw p TEL:993= ,?)1-2571) FAX:
'TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL$
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:p PLANS SUBMITTED: YES 0 NO❑
APPLIANCES]. FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE K
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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
AIf you have checked YES,please indicate the type of coverage by checking the appropriate box below.
K U LIABILITY INSURANCE POLICY gl, OTHER TYPE INDEMNITY 0 BOND 0
J OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
p� 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 appication wil e mp• ce with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. TO/b
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PLUMBERIGASFITTEERNAME:N i (um k r O LICENSE# SIGNATURE
COMPANY NAME: CC"P fog Pig ttc c.4 G0../ ADDRESS: 5 Frv`�i2c. .-• "✓�
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sCITY: S. yl6VIAAn.J1 . STATE: }"t✓J ZIP: Ori-`boy FAX: LS06 ` 35V 7,r717
TEL:(c74- ?FV- 2(vt' CELL: .Svrc4r S'Td — EMAIL. — tt
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V MASTER JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# 3 D/6 PARTNERV- ,❑# � LC t
111 MAY 13 2013 U
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