HomeMy WebLinkAboutG-14-645 S- I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• q1': yC/!�/4 OL4 h /MA DATE I PERMIT LI /'Iy—/(YYr�
JOSSITE„DDRESS: 1f C'cINO/ //�!r OWN .S NAME JC1 / Ac/gc%.
GOWNER ADDRESS: TEL' FAX'
'TE°R OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDE TIALPRT
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CLEARLY NEW:0 RalOVAT ION:❑ REPLACEEAENT:❑ PLANS SUBIv I I : YES❑ ND❑
I APPLIANCES? FLOOR--. Bsmt 1 I 2 I 3 I 4 5 I 5 17 I 8 9 10 111 12 13 I 14
I BOILER I I I I I I I I I I I
BOOSTER I I
it I CONVERSION BURNER I I I I I I I
I0/ COOK STOVE I I I I I I I
I DIRECT VENT HEATER
DRYER I I I I I I I
FIREPLACE
FRYOLATOR I I I I I
FURNACE I • I I I I I
GENERATOR
GRILLE
I INFRARED HEATER
LABORATORY COCK I I I I I
MAKEUP AIR UNIT I I I I I
OVEN I I I I I
I POOL HEATER I •1 I I I I
I ROOM/SPACE HEATED, I I I I I
I ROOFTOPUNIT
I TEST
I UNIT HEAT rc 1 I I I I
I UNVENTED ROOM HEATER I I I I I I I
WATER HEA iti i i I I I I
INSURANCE COVERAGE
I have a current liiabP;i v insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES EillEr❑
If you have checked M please indicate the type of coverage by chxtin a appropriate box below.
LIABILITY INSURANCE POLICY 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 subrnited(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 n oRrpfian all Pertinent
provision of The Massachusets State F umbfng Code and Chapter 142 of the General Laws. t—
PLUMBERWGASI-ItrtKNAKE9QN CJea/R'_Z,(Gl/f//° LICENSE`#/, /gt, RE
COMPANY NN/AIME 6-ate/melt p f/ ADDRESS: `Y c 6.c,5/x'/Q!v St
Crry: l Il n c/ STATE ZIP: ad-1 6? FAX:
TEL:6/7 7SU 16'C, CELL: EMAIL: R E CM-)
MASTER❑ JOURNEYMAN 5-1 NSTALLER 0 CORPORATION❑# fj y'er %�,
BUILDIN D /ARTMENT
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