HomeMy WebLinkAboutG-14-609 1 yw' polo, ,tO 041-0-1 To rat
h j 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS' 2'J lA/Ooc{CreS7"f_n (OWNER'S NAME Gran
GOWNER ADDRESS i_5'Anlr ITEL T6o�c_ZSFr-O43&f:(FAX
TP Il NT OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ,� RESIDENTIAL r •
CLEARLY NEW:D` RENOVATION:!.. REPLACEMENT:Li PLANS SUBMITTED: YES U NO N
APPLIANCES 1 FLOORS-. 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 •
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE _ _
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST t
UNIT HEATER
UNVENTED ROOM HEATER _
WATER HEATER
OTHER;
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES U NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [--41 ` OTHER TYPE INDEMNITY j[J BOND _f
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 `L.
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted 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 in compliance with all Pe nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Sean Hanrahan ( LICENSE#:31833J,jW SIGNATURE
MP rJ MGF U JP'+j JGF J LPGI L CORPORATION;J# (PARTNERSHIP, it ( LLC
COMPANY NAME' Sean Hanrahan Plumbing and Heating (ADDRESS 34 N Precinct Rd
CITY 'Centerville ( STATE i M.JZIP 02632 (TEL(-77 -2 b
FAX 508-419.6625 (CELL'same IEMAILI smusplumbirg@yahoo cam _ , j
4 DEC 18 2013
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