HomeMy WebLinkAboutG-14-977 I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
ft CITY: /v-y+f97 a- ti' /�/cv MA. DATE /tllir FERMI-1# 6 i9 %77
. JOESI ADDRESS: /6 �9 q//L� / 0 tS ME A' //A C/-LC C
GOWNER ADDRESS: LPGs 14, FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRIM"
r CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:�- PLANS SUBMffTED: YES 0 NO pi
10,,E APPLIANCES? FLOOR-• Bsnt 1 2 3 1 4 5 6 7 I 8 9 10 11 12 13 14
BOILER t I I
BOOSTER I I
CONVERSION BURNER I I
COOK STOVE j I
I DIRECT VENT HEATER I
DRYER I
FIREPLACE I
FRYOLATOR I
FURNACE I •
I I
GENERATOR I f
GRILLE I I
INFRARED HEATER I I _'
I LABORATORY COCK I I I
MAKEUP AIR UNIT I I I I
OVEN
I POOL HEATER •
I ROOM/SPACE HEATER,
I ROOF TOP UNrrUNIT HEATER
-I
TEST
UNVENTED ROOM HEATER I I I II I I I I II II
WATER HEAT:Tt I I I I I I _ I I I
I I I I I I I FE °. V
I I I I j
INSURANCE COVERAGE MALI ft
I have a current liability insurance policy or its substantial equ valentwh ch meets the requirements of A GL Ctl AY 11, .� NOy
tryou have checked YES please indicate the type ofcoverage bychecking the appropriate box below. BUILDINGDEP �Inny�}yT
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0 �60dP
OWNER'S[NSURANCEWAVER:I am aware that the licensee does not have the insurance coverage required by Chapter142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
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 will be I. ..m.france with all Pertinent
provision of the Massachusetits 5��mg Codi��er 1142 of the General Lzv
PLUMBER/GAS, II itRNAME: 1/' ru) /, 11 LICENSE o> f SIGNATURE
COMPANY NAME ADDRESS:
CITY: ice) PPJrin_ ei STATE/'T9ii�����;_ 77JPCP '/ • FAX
TEL�/�r�F',�l•>/" 9j ;ELL EMAIL
MASTER❑ JOURNEYMAN Ii' LP INSTALLER❑ CORPORATION❑4 PARTNERSHIP❑4 LC❑
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01.101(G I SPEC' O I lrCS TINS PAGEFORRINSPECTOIIU,SE ONLY ) INAL mai ON NOTES
�,fL9 01L e'en( 31/4 ie//r Yos No
TIII5 APPLICATION SERVES AS TI IE PERMIT ❑ ❑
FEE: $ PERMITP
$'LAN 1REVILWY NOTES
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