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HomeMy WebLinkAboutG-12-289 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t arikr el q :1111W;t CITY /1-.P.Mbu-t-� i MA DATE t 1/9/20/1 PERMIT 6412-ssaYe JOBSITE ADDRESS 4' 1-(omens O r OWNER'S NAME (Y)4 gTEIJ S G OWNER ADDRESS 3(P 14om PA'S Or ITEL IFAxMIN= TYPE OR OCCUPANCY TYPE COMMERCIAL DI EDUCATIONAL RESIDENTIAL® PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES NOp APPLIANCES 1 FLOORS BSM 1 2 3 4 4 5 6 7 8 1 9 1 10 1 11 1213 14 BOILER BOOSTER I _�_ { P CONVERSION BURNER I' r - C DIROECT VENT HEATER ; DRYER1 r FIREPLACE r ; FRYOLATOR I L _I _ FURNACE ' i I GENERATOR GRILLEill if I - - - INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT — P r— OVEN E - - - - I I POOL HEATER 1- ROOM/SPACE HEATER W - - - ' - - 1 I ROOF TOP UNIT I TEST f _ - - --ga- UNIT HEATER _ _ .i tr _Ir_- _ WATER HEATER VII` I - .- INVENTED ROOM HEATERj OTHER I � �� _r -----H- -±±t: 4,� INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY [3 OTHER TYPE INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER:I am 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are tau nd accurate to the b t of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in corn nce with a ne provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME James moms 1 LICENSE# 11521 SIGNATURE MP a MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 2445 P ERSHIP❑# LLC❑# COMPANY NAME: Spencer Hallett Plumbing and Heating ADDRESS 381 Old Falmouth Road Box 7 CITY Marstons Mills 1 STATE Ma ZIP 02648 TEL 508-428-6080 FAX 508-428-7991 CELL EMAIL spencer©hallettplumbing.com