HomeMy WebLinkAboutG-14-415 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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"" CITY: v v
TY: Y �— ....71-in MA. DATE CJ
/arb 3 PERMIT iYi
�`( JOBSITE ADDRESS/3 Cap 10 r s -PIA OWNERS NAME 0 en N r+`P /I
�]" OWNER ADDRESS: • SQ . -Q TEL: FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAIC
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT$2 PLANS SUBMITTED: YES 0 NO 0
APPLIANCES? FLOOR I ssr,Y, 1 1 1 2 1 3 4 5 1 6 7 1 8 9 1 10 1 11 1 12 1 13 1 14
BOILER I / I I I I 1 I I
BOOSTER
1
CONVERSION BURNER I 1 1 1 I I I I
. COOK STOVE
DIRECT VENT HEATER I 1 1 I I I
DRYER 1 I I I
FIREPLACE
FRYOLATOR 1 1
FURNACE I I I I I I
GENERATOR 1 I
GRILLE
INFRARED HEATER I I A
LABORATORY COCK 1 1
MAKEUP AIR UNIT I I I
OVEN
POOL HEATER I '
ROOM/SPACE HEATER 1 I I 1 .
1 ROOF TOP UNIT I 1
TEST I _ 1 I
UNIT HEATER— l I I
UNVENTED ROOM HEATER I I
'i- WATER HEA o.\ I
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t: WSURANCECOVERAGE
I have aRArt!ant Iiabili insurance policy or its substantial equivalent which mire s the requiremerts of MGL Ch.142 YES NO 0
't ou have checked YES please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 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 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have subrriltied(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be with all Pertinent
provision of The Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFI I^^I tit NAME I ct ti trill` LICENSE /5"3 Fa- _ L, SIGNATURE
COMPANY NAME•Yc� tC . ,.q.-01* 3PIt.�to---� ADDRESS: Ata- 1-�<o l�•+r Lc, La /4••••43
CITY L03 r'e t cZ r STATE: V ' (0 ZIP: 3 / FAX
TEL:o bl 3 )`•5--- 7 j., (dal: EMAIL:
MASTER 0 JOURNEYMAN P INSTALLER 0 CORPORATION 0 it PARTNERS:-IIP 0 4 ILC 0 4
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OUGflGAS LNSFEC'I'lI1NNOTES TRIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT
PLAN IIEPII;IY NOTES
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