HomeMy WebLinkAboutG-12-243 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY (Yamauth MA. DATE I (d /O.S I/i C
JOBSITE ADDRESS I 9 coon 1) C' R l� OWNER'S NAME I PERMITOC12 �3
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OWNER ADDRESS: ( S'A vh I TEL: I SO F -')C 0 US 'FAX;I
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL III t r rf
PRINT
CLEARLY NEW:In RENOVATION:❑ REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO 0
FIXUTRES 1 FLOOR-, Bent 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER R F I `;fF y
DRYER ' M '
FIREPLACE
FRYCLATOR 1111
FURNACE______________ S
u i�� ®�'■
111, 0
MAt(EUP AIR UNIT
POOL HEATER ��iL1V
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
I have a current liability insurance policy or its substantial a flal�ent meets COVERAGENSUCE e — //
requkements of MGL Ch 142 YES 0
If you have checked fu,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee sbninstba the Instance coverage required by Chapter 142 of the
Massadxnetts General Laws,and that my signature on this permit application waM this
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT
hereby certify that d of the details and Informaton I have submitted(or entered)regarding this application are true and actuate to the best of
Knowledge and that all plumbing work and installations performed under the pent Issued for this appi will In com with all P my
prat/fake of the Massachusetts State Plummbkpg Code and Chapter 142 of the General Laws.
PLUMBER/GASFRTER NAME I MANN "c•--\-L1 (ri I LICENSE I LW'E S TORE
COMPANY NAME:IlC 0,A pILYNiLkn .9- lir A7Ia
f IADO SS:I1 13r16%1aefr prove.
CRY: 111n%-tr V N.-e I STATE 0 21P:10 a- S Z a
I FAX ( ..
TEL: 1-77v- 9 e s(1 ICELL:I (A I EMAIL: I
MASTER Cc JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 IPARTNERSHIP 0 LLC❑#1
BELOW FOR OFFICE USE ONLY
MAL INSPECTION NOTES
ROUGH CAS INSPE(.'!?ON NOTES
_ � t9�1G is Ia-� nitme .�nl+nu ecoNo
(( vtc AS THE_ Yes PERMIT ❑
FEE: S PERMIT r
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