HomeMy WebLinkAboutG-13-1094 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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' _ - CITY: Stk yrCMq,TK MA. DATE: /_/14 ' PERMIT#//..t' 1Y
JOBSITE ADDRESS:_ 9 S' CT Li Q ei 0(. trent C'1P OWNER'S NAME K t it In Jo S4 F'Ln
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C OWNER ADDRESS: n w's 'e j TEL FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0--------
PRINT
/PRINT
CLEARLY NEW: NOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
TAPPLIANCES1 FLOOR I Bsmt 1 2 1 3 1 4 5 6 7 8 9 1 10 I 11 1 12 13 1 14
N1 BOILER I ' I 1
Evl,tlr'J-BOOSTER) I
ILLI etONVERSION BURNER �1' I I I I I
> ,OOK STOVE / ."-rd- ' e):I I I I I
cQIRECTVENT HEATER
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In : .-DRYER ii I III I I
0 I FIREPLACE
RYOLATOR I I I I I
LII FURNACE! I I
fif,` 'GENERATOR I
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INFRARED HEATER I 1 ' E a u � �I
LABORATORY COCK I I
MAKEUP AIR UNIT I n+-' ' 701-3OVEN I LV
POOL HEATER I 'I I rwpir,DEPT_
ROOM/SPACE HEATER -
ROOF TOP UNIT I 1 r
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TEST
UNIT HEATER _ I
UNVENTED ROOM HEATER I
WATER HEATER I I
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES LJI'NO ❑
If you have checked YES,please indicate the type of coverage by 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 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 wil • n�',ith all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / i��
PLUMBER/GASFITTERNAME: _l?n 5414 ( LICENSE# ) 994 - ` ' SIGNATURE
COMPANY NAME: ADDRESS: V — ei Za 5' I
CITY• `-h calevti STATE: k31- ZIP: 030'7 7 FAX:
TEL: CELL a 03 -23V/•to Li`I EMAIL: j SA(L)S IG,' cs 4J 1v1 rat 1- , C
MASTER 0 JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LW 0#
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
pie oft LAtt C¢/111/x__ Yes No
THIS APPLICATION SERVES AS TI IE PERMIT ❑ 0
FEE: $ PERMIT ft
PLAN REVIEW NOTES
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