HomeMy WebLinkAboutG-14-400 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
4 CITY: (,..,est vittNio.;sLi MA. DATE: /C lash/ S PEEMIT# vei— n0
JOBSITEADDRESS: c) SovTk sea s\ OWNER'S NAME MR aUtcis
ocP 98
G OWNER ADDRESS: TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL CI
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:71 • PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR-+ Bsrt 1 1 2 3 4 1 5 6 1 7 1 8 9 1 10 1 11 1 12 1 13 1 14
BOILER
BOOSTER 1 1 I I 1 f
CONVERSION BURNER I 1 I I
COOK STOVE I _ I I
DIRECT VENT HEATER
DRYER
FIREPLACE I -
FRYOLATOR I 1 1 I 1
•
FURNACE X f I I I -
GENERATOR 1
I GRILLE 1
INFRARED HEATER - _
LABORATORY COCK 1
MAKEUP AIR UNIT
OVEN _
POOL HEATER 1 I I
1 ROOM/SPACE HEATER .I i
I ROOF TOP UNIT
TEST 1 I I I
UNIT HEATER 1
UNVENTED ROOM HEATER I I y
WATER HEATER I I I I I
I-
I -
INSURANCE COVERAGE
r�T have a'current liability insurance policy or its substantial equnralentwhich meets the requirements of MGL Ch.142 YES 1�1 NO ❑
LLIouhavecheckedIES please indicate the type of coverage by checking the appropriate box below.
o \' l LIABILf1 Y INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
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_-p INSURANCE WANER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
iI_Massac usetts General Laws,and that my signature on this permit application waives this requirement
L7 !z n
1 ' it 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 amine and acs mate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this appfioation will be) compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. <X
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o/�/,��, PLUMBER/GASFII I thNAME: Ca',WA", Fri2'em10 LICENSE# if!?- " v SIGNATURE
/ M COMPANY NAME:/n 2 PAJ,44- RI T'P ADDRESS: 3(41 P;. t S 1
Ctl-f( CITY: Cer\Terl).\*'e STATE M/' ZIP:Oa(&3P FAX:
ELJJ:
r��,,T� CELL: - f )26-9,3a aim:t
/ t K �N,ASTER Ii JOURNEYMAN❑ LP INSTALLER 0 CORPORATION❑4 PARTNERSHIP 0 4 U C El#____
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OUGI[ .AST P �- >• - WI PAGE FOItINSPIECTO1RUSE ONLY J�1NALINS I' en ON NOTES
Yos No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT 0
J'LAN REVIEW NOTES