HomeMy WebLinkAboutG-12-689 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY Yamwuth
�� I Po I, Ma DATE ( �'/y/la I PERMR#
JCBSITEADDRESS I /9 sr/Alp 1,4 I OWNER'SNAME I 'flR Sd/Tu FF J
GOWNER ADDRESS: I I TEL l I I FAX:I
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YPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL IR
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXUTRES 7 FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER j
f•\ BOOSTER
t\ CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
(4 FIREPLACE
b FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
k POOL HEATER
ROOM!SPACE HEATER
'S. ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
• INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL C [�2 LK 135�]fNQ
If you have checked LEI please indicate the type of coverage by checking the appropriate box below. II1) V U
LIABILITY INSURANCE POLICY [j]V OTHER TYPE INDEMNITY 0 �uoND 84Y 0 4 P012
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required b &papt&'t42404EPT
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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 true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit Issued for this application in cam Bance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, Zji%
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PLUMBER/GASF ITER NAME I (Sr Il F rigger I UCENSE# /r. 9 . SIGNATURE/
COMPANY NAME: I M2 pkt,A-1?ti a IADDRESS:I 3,6 elopir mine. ct✓
CITY: I CPnTer,... i e I STATE IS LP: I O%3 o1 I FAX:
TEL I I CEU I I EMAIL I
MASTER p JOURNEYMAN❑ LP INSTALLER 0 CORPORATION 0# PARTNERSHIP❑#C1 LLC❑#
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