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Home My WebLink AboutG-12-801 I r� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: Y4mnv7774 MA DATE: 44e-'d Al PERMITSCIYQ I '^fin• JOBSITE ADDRESS: Z2 -1457C C4 T SS-1—r 0r+C,6WNER'S NAME: albs& v'Rc7Y GOWNER ADDRESS: :S4•n/= TEL: 779--aCOr'l a5FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:t?' PLANS SUBMITTED: YES 0 NO®- APPLIANCES? FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER R F - E I V F n COOK STOVE DIRECT VENT HEATER DRYER N 2.ri 2012 FIREPLACE • FRYOLATOR FURNACE ff' C�°A°'MEti1 ©Y. GENERATOR • Il # a GRILLE INFRARED HEATER LABORATORY COCK • MAKEUP AIR UNIT OVEN • POOL HEATER ROOM I SPACE NEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO 0 If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY,' OTHER TYPE INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER:lam 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 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 m iance with a�ertinent provision of the Massachusetts Sta.e.Plumbing Code and Chapter 142 of the General Laws. r i PLUMBEWGASFITTERNAME ion �T� //sem LICENSEkz S NA�� COMPANY NAME: 7/t PtK zincADDRESS: `fW G-+0Gfitt*3744/if RDS CITY: (50077/}+ 4-41441 S STATE: M4, ZIP: oaa0 FAX J��c�/C��t too,' TEL: `3$5.1//P7 CELL: EMAIL' /41-fi bnii r--"OG 0E/4f o? '��Y T MASTER Jr"JOURNEYMAN❑ LP INSTALLER❑ CORPORATION g-LiziLea PARTNERSHIP 0= L_C r ROUGH GAS INSPECTION NOTES 'TIIIS PAGE FOR INSPECTOR USE ONLY - FINAL INSPECTION NOTES Yes No; THIS APPLICATION SERVES AS THE PERMIT 0 ❑- FEE: $ PERMIT# - PLAN REVIEW NOTES • • 4.