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HomeMy WebLinkAboutG-14-555 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � 5 j ` _ • ^---_-----r CITY 0412moci t MA. DATE 6 Lie x01-27 PERMIT# /7/9-15-53- JOBSITEADDRESS: 5 " ofv£QLy PC'h OWNER'S NAME n''fref Lt- oIC-41/e9H97✓ G OWNER ADDRESS: 5 c grvfP'-y yl 19 TEL: 6r7 .276 i/A'I'TAx: TYPE OR OCCUPANCYTYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑ APPLIANCES? FLOOR-. Bsnx 1 1 1 2 3 4 5 1 6 1 7 1 8 1 9 1 10 1 11 12 1 13 1 14 BOILER 1 I 1 I I 1 I BOOSTER CONVERSION BURNER I I 1 I COOK STOVE II I I I I DIRECT VENT HEATER 1 I DRYER I I I I 1 I FIREPLACE I I I I I I - FRYOLATOR FURNACE I Y I I 1 GENERATOR GRILLE INFRARED HEATER 1 I I LABORATORY COCK I , _ MAKEUP AIR UNIT OVEN l I POOL HEATER I ROOM/SPACE HEATER I I ROOF TOP UNIT I I TEST I I I UNIT HEATER I I UNVENTED ROOM HEATER _ WATER HEATER I I I 1 I INSURANCE COVERAGE / I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES © NO ❑ If you have checked YES,please indicate the type of covers y checking the appropriate box below. LIABILITY INSURANCE POUCY 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 ❑ 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 applicatioq will be' "II• -, - .iii all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERIGASIItNAME SITIH£II/ Pconf&7" LICENSE 505- %a HaNATURE —.- COMPANY COMPANY NAME:Sientin/ Pot3c i5 (//.5 h1/2/7" A.F/G ADDRESS: /7 2-1-'1f 012-- CITY: LCITY: PLy/l'1GtrT it STATE: /14/4 ZIP: 01,9-3d0 FAX TEL: CELL' go Org. 090 EMAIU 'r 57-aPt•/ is i MASTER❑ JOURNEYMAN/LP INSTALLER❑ CORPORATION❑if PARTNEP.-ft- — _C C ft DEC 0 6200113 r t NT By ROUGHCASINSI'LCC10NNOTES THIS PAGE FOR INSPECTOR USE ONLY yINALINS mai ONNOTES Yes No TNIS APPLICATION SERVES AS TI IE PERMIT ❑ ❑ FEE: $ PERMIT# )'LAN REVIEW NOTES Commonwealth of Ma usetts , Division of Registraliorf., f Board of Plumb' .o-e.n.h.. • i • ti STEPH" TT �fl 61 SC" 'i2cl.e o • CATAUM A- xta _r Joumeyma t. 1M 'Jae GF5104-J 05/01/2014 004714 License No. Expiration Date. Serial Na