HomeMy WebLinkAboutG-14-345 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
•^ ef CITY: YIP—Ai C1/47771- MA. DATE: O—/C— /3 PERMIT big—SK-
�y JOBSITE ADDRESS: 7/ 7)C" 5 if/LL f7OWNER'S NAME PS/72,4? LPPP
GOWNER ADDRESS: 57941G TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:K RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR 1 Bsmt 1 1 2 1 3 4 5 6 1 7 8 1 9 1 10 11 12 1 13 14 _
BOILER 1 I I I
BOOSTER
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CONVERSION BURNER ( I 1 I I _I I
COOK STOVE I / I I I
DIRECT VENT HEATER ( 1 _
DRYER
FIREPLACE
(�\ FRYOLATOR I 1 1 I I I
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;c) FURNACE I I I I I 1 I 1
GENERATOR 1
19.-- I 1 I I I I
GRILLE
INFRARED HEATER I
LABORATORY COCK I
MAKEUP AIR UNIT I
OVEN
POOL HEATER I • 1
ROOM/SPACE HEATER
1 ROOF TOP UNIT
TEST - I � -
UNIT HEATER
UNVENTED ROOM BEATER
WATER HEATER t , I I I
het
1013
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MANS INSURANCE COVERAGE
I lave a c tiab yrahce policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1KNO ❑
OD‘‘
\ 13!ou h checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY gOTHER 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 will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �y BcDb P----"a
PLUMBER/GASFITTERNAME: 6 ruMEY LICENSE4/IPIC SIGNATURE
COMPANY NAME nity t rt di . �ADDRESS: /89 ‘4)71/n� ,�5 ` A
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CITY: en�//U�-3 � /'/
/ STATE /51 ZIP: 01660 FAX
TELS 726 e3L 8 CELL: EMAIL:
MASTER gc JOURNEYMAN 0 LP INSTALLER 9 CORPORATION 0# PARTNERS'tP 0 4 LG 0
ROUGH GAS LNSV rCTJON NOTE THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
,('bhi 6/19 OK G2/1- /6 A-6-13 Y
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT I
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