HomeMy WebLinkAboutG-14-986 7, ter,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
',tat, CITY migrirg sT ijJ^Ul _ . MA DATE 4//9//te I PERMIT# b�%� l9
DJOBSITE ADDRESS i96-
W1s L�IOWNER'SNAME Or-P r ! �I
OWNER ADDRESS _ —_� �.I TEL (FAX
TYPE OR OCCUPANCY TYPE ' COMMERCIAL J EDUCATIONAL _J RESIDENTIAL.
PRINT
CLEARLY NEW:L.i RENOVATION:e REPLACEMENT:LI PLANS SUBMITTED: YES _I NO._.I
APPLIANCES 7 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM 1 SPACE HEATER
ROOF TOP UNIT
TEST I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i.J NO _J '
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J OTHER TYPE INDEMNITY BOND I J
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 Li AGENT '_i
SIGNATURE OF OWNER OR AGENT
I P ass
PLUMBER-GA FI E ken 11012 are a and a•• rate to the best of my knowledge
hereby certifythat allthe details and information I have submitted or entered regarding this application
and that all plumbing work and installations performed under the permit issued for this application will be in r ce -II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � �I/
S TT R NAME LICENSE# ( / SIGNATURE
MP +,1 MGF JP _J JGF J LPGI J CORPORATION 4J# 3541 j PARTNERSHIP. 1CLC%#� 7: 1 ll
COMPANY NAME: duarteplumbing Inc ,ADDRESS 37 Collins ave '_ I
CITY centerville J STATE ma f ZIP 02632 TEL 5 1 20-2tWWY 19 ?G''} i_1I
FAX 508-775-9135 CELL EMAIL kenduarte37@hotrnail.com L •fu
By
Z'E,121 NiENT j
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT
PLAN REVIEW NOTES