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HomeMy WebLinkAboutG-13-647 MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK ie. ' all I q yrr)d rJ r�/7 MA DATE 75/3- l'`!7 JOBSrmEADDRESS / 9 field IpVVNFJ7SNANIE t Pne� Gormgn_1 OWNERADDRESS - ITS (FAxI TYPE ' OCCUPANCY TYPE COMrE PRIM' OCCUPANCY EDUCATIONAL r� �-� IMr-[ CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:133./.....-- PLANS SUBMITTED: YES 0 NO fl APPLIANCES 7 FLOORS-` 894 1 2 3 4 5 6 7 i 8 9 10 11 12 13 14 r BOILER --4-____ i _ _CONVERSION f— - 'L t .---. waef>=lam / '� CONVERSION BURNER • -._ COOK STOVE --EN DIRECT VENT DRYER A 3 t ___.. FIREPLACE --- FRYOLATOR C / r f--cr- • r FURNACE - 4.C G- ENERATOR �I= p. _ _.- F —tet L. GRILLE r- ,�_ — INFRARED HEATER o- R - - LABORATORYCOCKS �e-_ �- MAKEUP AIR UNIT ` �eJ OPEN s _ POOL HEATER - ROOM/SPACE HEATER _^ ` - _ ROOF TOP UNIT _ - - "'TEST I (_ _ U- NIT HEATER - • - UNVENTEDROOM HEATER f a -T------ - WATER HEATER - OTHER I .- '-,e- Y t .... _r_. . INSURANCE COVERAGE I have a current liability insurance policy cc Its wbsIandal equivalent sada meets the requirements of M .Ch.142 YES IFYOUCHECKEDYES,PLEASEINDICATETHETYPEOFTHEAPPROPF ATEBWCBELOW Ian - LYINSURANCEPOLJCYC[ y RTYPEBIUEMNTT❑ BOND 0 OWNER'S INSURANCE WAIVER I am aware that the licensee goes not have 8w hisma ce CMOS required M Chapter 142 of the Massachusetts General Laws,and that my sgirdme on this puna appec+>ron waives this requirement CHECK ONE ONLY: OWNER 0 AGENT D SIGNATURE OF OWNER OR AGENT -I hereby cat/that ail d the derails and.&.. 4an I haws submitted oraewed regacig Stappica nave tare and accurate to erre best o otv�n^1'ieoaMed9e and that as stinting nark and:Wapedantws pedant under the pemil issued for bis appicaion ani be in.. . ... •it ` /ti a tit Massachusetts State Muting Code and Chapter 142 or the G�erve al Laws- - I PLUMBER-GASFITTERNAME I/ en- - ,l • night) 1 LICENSE/al* - .I .." -iu MP© MGF❑ JP( 4&fl LPGI D CLORPORATION[l01 I PARTNERSHIPOil I� I COMPANY NAME: vmai/iv !l'/dn)Jiny IADDRESS! 0?04. To C1+ (---5-41-1-11- cm' irk{cmr W7eh igm _ srATEImR twI Dap g..3' #ra! COI-pc3�Wy JWP y FAX i CELLI EMAILI r -§ f. ,a sr kg t JAN• /o% �� LUat)IN D BY