HomeMy WebLinkAboutG-12-584 s "h
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY IYamwuth I• MA. DATE I /a o/ia I PEP rrG/Z-Sy
JOBSTTEADDRESS IX43.7 Riae Escggr16(4OWNER'S NAME I/ J; CilaeI 14sreLti I
G OWNER ADDRESS: I I TEL' I I FAX I
TYPE OR OCCUPANCY Type COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW: % RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXUTRES 1 FLOOR-, Bent 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER I
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT '
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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I have a current labilihr Insurance INSURANCE COVERAGE
1 policy or its substantial equivalent which meets Me requirements of MGL Ch.142 RE .Pi' • n
M you have checked yam,please Indicate the type of coverage by checking the appropriate box below. V E D
LIABILITY INSURANCE POUCY% OTHER TYPE INDEMNITY 0 BOND 0 MAR 2 0 012
OWNER'S INSURANCE WAIVER:I am aware that the licensee the insurance coverage r by ' Q'/,
Massachusetts General Laws,and that my signature on this permitm this application Rarequirement ° J ' DEPARTMENT
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that all d the details and Information I have submitted(or entered)regarding this application are hue and:y rate to the best of my
Knowledge and that all plumbing work and krofallatbri performed under the pem*Issued for This application will ,. r withal Peanut
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4°1
PLUMBER/OASFIITER NAME: I A I e x B SCTs9a I LICENSE sf 11114707 SIGNATURE
COMPANY NAME:( P)SQ5q Bso9- t% ANtory. JADDRESS:1X70) k050.J7 t 1 #oQ1
CITY: IUjawm;q/ ISTTATE rim ZIP: Rt lliTle FAX I
TA:oto to mos/ 'CELL I I EMAIL: I
MASTER,JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 it (PARTNERSHIP 0 it I LLC 0 I PI
BOUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY UNAL INSPECTION NOTES
Yes 140
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: ST PERMIT
PLAN REVIEW NOTES
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