HomeMy WebLinkAboutG-12-454 MASSACHUSETTS UNIFO• ' 1• •LICATION FOR A PERMIT TO PERFORM GAS FITTING WOR!(
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OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL I 0 RESIDENTIAL la"
Co C 'CLEARLY NEW:9 RENOVATION:0 REPLACEMENT:0
FIXUTRES 1 FLOOR-, Bamt 1 2 3 4 5 PLANS SUBMITTED: YES 0 NO to
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BOILER8 9 10 11 12 13 14
BOOSTER
CONVERSION BURNERINN
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OK STOVE
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DIRECT VENT HEATER la ______�__
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATORGRILLE
LABORATORY =====®�_____
OVEN AIR UNIT
POOL
ROOM.HEATER
ROOM
FTOUNIT SPACETER •
ROOF TOP UNIT
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UNIT HEATER •
UNVENTED ROOM HEATER - la___
WATER HEATER• •
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I have a current Ilahility insurance gong or its substantial INSURANCE COVERAGE
equivalent which meets the requirements of MGL Ch 142 YES erNO 0
If you have checked,yL$,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY Er OTHER TYPE INDEMNIFY 0 BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee 0
surance cov
Massachusetts General Laws,and that my signature on this permit waiv this requirement
required by Chapter 142 of the
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that all of the details and Information I have submitted(or entered)regarding this application are he and accurate to . : .:.t of
Knowledge and that all plumbing work and Installations performed under the my
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Law this
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PLUMBEWGASFITTER NAME 'At IC 0 t w a' 4 \ LICENSE# 7 - /�� �v:
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COMPANY NAME ►A , e W = &r LU(CQ.;
ADDRESS: s � lriltral
CITY: ligm STATE
ME ZIP: FAX 1 I
TEL to i '," E' CELL: I hr
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MASTER IQ JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 fine PARTNERSHIP 0#r_1 LLC 0#
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