HomeMy WebLinkAboutG-14-575 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-0-0\3/4 Yat00 MA. DATE De_c- 06- a013 PERMIT# b/y 57r
JOBSITE ADDRESS 14 Gtnc3e r 'rid. 'C>, OWNER'S NAME `Ant, at,
GOWNER ADDRESS: TEL: 61540 34S -503' FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: D. RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO
FIXUTRES 7 FLOOR-» Bsmt 1 2 3 4 5 6 7 8 9 _ 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM ISPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER X
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.C ��
If you have checked YES,please indicate the type of coverage by checking the appropriate box below. E @ "- i1
LIABILITY INSURANCE POLICY Ly OTHER TYPE INDEMNITY 0 = J D ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required b Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement BUILGN. 7r
CHECK ONE ONLY: OWNER 0 AGENT 0 947
SIGNATURE OF OWNER OR AGENT 52Z
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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 ap lication will b in complian with II Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTERNAME: MU1- ekbyb.n4,,,i- 9 LICENSE# 1ZjOfl SIGNATURE
COMPANY NAME: t t n S ADDRESS: G5rireratir c J
CITY: `(11a{6}ans in v1(1.5 _ STATE: Yb'A ZIP: aa 64A FAX:
TEL: $d8 1-) I^2?f!I CELL EMAIL:
MASTER/JOURNEYMAN 0 --LP INSTALLER❑ . CORPORATION❑# : ,- . ?PARTNERSHIP di LLC❑#
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