HomeMy WebLinkAboutG-14-639 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: 7arr.0v 1"`^ Ma. DATE /'Vali/lam PERMITt b/Y-639
JOBSITE ADDRESS: al( 54 64k Rc't OWNER'S NAME "b)'n /9°c-cv{y re
OWNER ADDRESS: TEL` FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIALa
PRINT
c1 f CLEARLY NEW:in" RENOVATION:0 REPLACEMENT:0 PLANS SUBNIII i ED: YES❑ NO❑
` APPLIANCES? FLOOR-4 Ssnt 11 12 3 1 4 5 6 7 1 8 1 9 10 1 11 12 13 14
BOILER I I I I
BOOSTER I I I
CONVERSION BURNER I
COOK STOVE I I I
I DIRECT VENT HEATER I I
DRYER I I
FIREPLACE
FRYOLATOR
FURNACE I • I
GENERATOR I
GRILLE
INFRARED HEATER I L
LABORATORY COCK I I I
MAKEUP AIR UNIT I I
OVEN I I I I
POOL HEATER I I
ROOM/SPACE HEATER I I I I
I ROOF TOP UNIT I I I I I
TEST
UNIT HEATER I I I
UNVEN T ED ROOM HEATER I I I I_
WATER HEATER I I I I I a tit
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INSURANCE COVERAGE " �p
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MCL Ch.142 YES 4:(NO 0
If you have checked X,please indicate the type of coverage by checking the appropriate box below. By___S./_L_/62.15—
LIABILITY INSURANCE POLICY.e" OTHER TYPE INDEMNITY ❑ BOND ❑ Y'/. 00
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 ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have subrritfed(or entered)regarding this application are tie and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the pent issued for this application will be in cornpr n w Pertinent
provision of the Massachusets Stale Plumbing Code and Chapter 142 of the General Laws. ^�
PLUMBER/GASP'i k.KNAME ,>CC� --6JGg LICENSE*3I�GS-S L/,, l(3�lATURl=�
COMPANY NAME: S �-yAS > ADDRESS: & eattow ITou S C R
CITY: SI kowt STATE ZIP: o2G ( a FAX:
TEL: ,c0 —737- 71(I cm: EMAIL:
MASTER 0 JOURNEYMAN ej" LP INSTALLER❑ CORPORATION 0 it PARTNERSHIP❑: LLC 0 a
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