HomeMy WebLinkAboutG-14-647 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
' gTlf: W'es7 ray), w� Mk DATE 11/11 Oaff 3 PERMIrr fa"/Y 97
/� I //�1 ✓ ,9//�� //
G JOBSITEADDRESS' Sri 11— ►Ja
L
kt 1ta OWNER'S ftr. Vc/4✓r.
OWNER ADDRESS: TEL FAX:
PE°R OCCUPANCY TYPE: COMMERCIALEDDUUCA11ONAL ❑ RESIDENTIAL
CLEARLY NEIN:0 P,ENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0
APPLIANCES? FLOOR-. Bsrd 1 1 2 3 1 4 5 6 7 1 8 19 110 11 12 13 I 14
BOILER
BOOSTER I I I
CONVERSION BURNER
COOK STOVE I I I I
DIRECT VENT HEATER
DRYER I
FIREPLACE I I I
FRYOLATOR
FURNACE I I
GENERATOR I I
I GRILLE I
INFRARED HEATER I I I I
LABORATORY COCK I I I I I I
I MPJ PAIRUN1T
OPOOLHEATER •
ROOM/SPACE HEATER I I I I I I I
I ROOF TOP UNIT I I I I I I
TEST I I I I I I I I
UNIT HEATER I I I l
-=•w, •AisisI I I I l I
6s i
II I
i 17 38i3 I I I I I I I
INSURANCE COVERAGE
A r,t: •• ilia!i! ce policy or its substantial equivalent which meets the requirement of MGL Ch.142 YES NO 0
Ay•. eve checked please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCEWPJVER:I am aware that the licensee does not have the insurance coverage required by Chapter142 of the
Massachusetts General Laws,and that my signature on this permit applicadon 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 aretlue and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this applirafion will be in witl)all Pertinent
provision of the Massachusefls Staten Plumbing Code and Chapter 142 of the General Laws. l/u"'t .eit
PLUMBERIGASFIIItKNAME f<atrr "MA IIt' LICENSE# 61"/331' SIGNATURE
COMPANI'NAME )J O/L��Vn ni n} ftaa7n j ADDRESS: f6 iditc
CITY: wrs ? Krrnou`7STATE:Al ZIP: Oa173 FAX:
• TEL. 72y 3 ,1111/ — CELL EMAIL
MASTER 0 JOURNEYMAN EI/LP INSTALLER 0 CORPORATION 0 z ?ARTNERSH P 0# LC❑