HomeMy WebLinkAboutG-14-678 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
WIC's /
.!-11—F CITY ;_ MA DATE k[�Citi_F..__1PERMIT# H7 —671
JOBSITEADDRESS' ._s"'"" „ __i OWNER'S NAME _►iefr{arv*\ Lams.--
GOWNER ADDRESS 'r TEL___ - _ TEL71t4 -Ota—gt AFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL _j EDUCATIONAL _,; RESIDENTIAL .IS
PRINT
CLEARLY NEW:L,:.1 RENOVATION: _I REPLACEMENT: .,' PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER Ii i ' I
BOOSTER _
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OOEN31/416U
POOL HEATER _.. ' R F C
ROOM ISPACE HEATER
ROOF TOP UNIT
TEST , F 1Q 201111
UNIT HEATER '
UNVENTED ROOM HEATER nt ci6inGOLI-Akily ti"t
WATER HEATER
OTHER _. _._._._.-. .j . _)___. ,_...._',
INSURANCE COVERAGE H ''
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 EYES(ONO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY +I OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachus eneral Laws my signature on this permit application waives this requirement.
— CHECK ONE ONLY: OWNERT ,AGENT CI
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 and acc r. to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance •' • : I Peru •-s=ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 2alal_kla____� _ LICENSE#p.jjTfJ� SIGNATURE
MP _ I MGF _.I JP JGF',..1 LPGI J _,CORPORATION I# �_ PART : RSHIP ..-_# _ LLC #
_
COMPANY NAME: 70 bn,Syn r _„ -. ._
_!ADDRESS„2 y £,i Lane . . ..
CITY �aCijkh _ STATE IZIP Q _ kcjTEL_77.1 AM Ore
FAX_____ ICELL IEMAIL._._.____-___._.
I - 'Commonwealth of Masg3xhusetts
—`.7.7.7.7Division of RegistratioA^n\
• 'rk „ Board of PlumbiL.EE�v11?eL� -
Le
; JOHN C1.4 IT r=is
• +:1; • 24 SAND iLc2EE;- l— �-
HARWIC , : —
Joumeyma g ft
PL32777-J 05/012014 “ `Y 05015
License Nc. Expiration Date. Serial No.
a.