HomeMy WebLinkAboutG-14-309 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: W c:ST /fT % l04-L MA. DATE: 9/07�J/I3 PERMIT# t/lV SCT
JOBSITE ADDRESS: 72 Higgins Crowell Road OWNERS NAME: Jeanne Critzer
tet G same 508-775-0066 508-778-2276
OWNER ADDRESS. TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:C9 REPLACEMENT:0 PLANS SUBMITTED: YES® NO❑
APPLIANCES1 FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _
BOOSTER
�I I
CONVERSION BURNER
1\b COOK STOVE X
DIRECT VENT HEATER
DRYER
FIREPLACE X
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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 coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY d 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 ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true an. :ccurate to the ..,st of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will Iti;;;;Iifpliance W all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: Jason Drew LICENSE# J-'50715 SIGNATURE
COMPANY NAME: Drew's Plumbing ADDRESS: 6 Agassiz Rd
CITY: Brewster STATE: Ma ZIP: 02631 FAX:
TEL:508-367-5739 CELL 508-360-1400 EMAIL: drewsplumbingcape@yahoo.com
—4v1ASTFR D.70,,,,,F LP INSTALLER❑ CORPORATI3N n PARTNERS-1P__
OCT 3..�
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
f one Ost 6/9l 61/11/ Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: S PERMIT S
PLAN REVIEW NOTES
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