HomeMy WebLinkAboutG-18-6811 l -A-
4)r
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'sal=. CITY So U1+1 4 02yy1/4()%14-4N MA DATE 1.40,}, -5Od01E1 PERMIT#,rPeri8-ovo i
JOBSITE ADDRESS[ al n r uj txci 6 Krems}- I OWNER'S NAME J
G OWNER ADDRESS TE FAX IIIIIIIIIIIIIII
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY NEW:' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER l 1 'l l i i i ( 1 1 1 1 '1 1 1
BOOSTER I It
CONVERSION BURNER
COOK STOVE j 1 1 1 1 1 1 1 1 1
DIRECT VENT HEATER 1 1 1 1 , 1 1 1 1 1 1 1
DRYER
FIREPLACE 1 1 1 1 1 {, 1 1 1 1 1 1 1
FRYOLATOR $ k 1, I
FURNACE
GENERATOR1
lililLiTil
1111
POOL HEATER
ROOM ISPACE HEATER = T 'jj a]
ROOF TOP UNIT lr: i pl� ,
TEST �I^'
UNIT HEATER �r ; 11
UNVENTED ROOM HEATER I r 1 1 1
WATER HEATER L
OTHER r l� i ail.ar 0W ltk� lY
1 1 -1-1, _1 �
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ✓❑ OTHER TYPE INDEMNITY❑ BOND ❑ _ --- --
OWNER'S INSURANCE WAIVER:lam 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 D AGENT D
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true an• -
: rate • I e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in plia AZ all P:it ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
A-
PLUMBER-GASFITTER NAME Bruce Sison LICENSE#32379 SIGNATURE
MP MGF❑ JP El JGF❑ LPGI❑ CORPORATION❑#Min PARTNERSHIP❑M I LLC❑#.111111111111111111
COMPANY NAME:Sison Plumbing&Heating ADDRESS 1730 Washington Street
CITY Walpole STATE MA ZIP 02081 TEL 774-248-0063
FAX 1 CELL 'EMAIL sisonplumbing@gmail.com
( 7.6 &11-7,1z��� �� /�yIq
4
F: ..r gy3r t r IF frilly'
sa
I
+ y w-
}
g
ttr r.
R) a xx -2 "'� ;5� , 4•1:?"':' � . 3d. xA -7,44ay n $
•
iin . f `t rx.. fii . . f oy � Ito d z z� rtF. _ ^ v' 4 l£ s« - f ,, m '-'4:1:54P-44,41=--.-..
-.-..' .}, T4
4---41.--_- liar I, M1. �YpI� '[ ta'.���w3�� � -p t
..z - ,: Va`
•
.'
{
f i