HomeMy WebLinkAboutG-14-917 MASSACHUSETTS UNIFO- APPLICATION FORA PERMIT TO P RFORM GAS FITTING WORK
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JOBS (ADDRESS. e WI�pSpNAJAE 76217/1/4/G OWNER ADDRESS* EL100 / ~4/WFAK
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW: RENOVATION:0 REPLACEMENT:R PLANS SUBMITTED: YES 0 NO[
APPLIANCES? FLOOR-4 Bsmt 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 10 1 11 12 13 1 14
BOILER
I
BOOSTER I I I 1
CONVERSION BURNER I I I I I I
COOK STOVE I I I I I I I
DIRECT VENT HEATER I I I I I
DRYER I I I
FIREPLACE 1 I I I
FRYOLATOR I I I I I I I
FURNACE I I I • I I I
GENERATOR I I
GRILLE I In1
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT I I I I I
OVEN
I POOL HEATER I
ROOM/SPACE HEATER I Ina I I I I •
I ROOF TOP UNIT I I I I I
1 TEST I I I
UNIT HEATER I I I I -
UNVENTED ROOM HEATER Ela I
WATER HEATER I I I ' I
I nil I I MIS
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL Ch.142 YES f] NO 0
If you have checked YES,please indicate the type of covera by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
•
OWNER'S INSURANCE WAIVER 1 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that at of tie details and information I have subrrted(or entered)regarding this app6caiion are hue and accurate to the best of my
Knowledge and that all plumbing work and instillations performed under the permit issued for this applied. All . in compliance with .II •s nent
provision of the Massachusetts S ' umbin Code nd Cha ' 142 of the Gen Laws. /
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COMP E:�`'eSS77//� II/U/�1�1/ki ADDRESS: 4 4.//ePri
CITY� /�mom STAT/M1 ZIP: 4e 7 .e2 FAX:
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/JOURNEYMAN -rte
MASTER[� JOURNEYMAN 0 LP INSTALLER❑ CORPORATION 017 PA TlaSiLP D —1 11C Q a
\, APR 17 2014 ✓
OUGII G SPL " • ► • r, ' TILTS PAGE FOR INSPECTOR USE ONLY FINAL INS PED'ION NOTES
Yes No
THIS APPLICATION SERVES ASTIIE PERMIT ❑ ❑ -
FEE: $ PERMIT A
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